Comment
Early mobilisation in ICU is far more than just exercise
It is easy to consider early mobilisation in the intensive
care unit (ICU) solely as an exercise intervention.
However, it has become increasingly clear that such
a simplification is wrong. Instead, early mobilisation
in the ICU is a complex intervention demanding
interdisciplinary coordination and communication.
Previously published randomised controlled trials1,2
(RCTs) have hinted at the importance of coordination and
communication. These RCTs have uniformly increased
the amount of time physical therapists were available to
patients in the ICU.1,2 But close readings of those trials, and
conversations with their investigators, show that much of
the physical therapists’ time went to preparing patients
for physical therapy, rather than delivery of active physical
therapy itself. When one of our ICUs implemented an early
mobilisation programme (University of Michigan Health
System Critical Care Medicine Unit, Ann Arbor, MI, USA),
we found that the physical therapists budgeted half their
time per patient for coordination roles, and only half their
time to delivering active physical therapy per se. Similarly,
the international TEAM ICU mobilisation trial3 used an
extra hour of a physical therapist per patient per day to
do such coordination as an integrated part of the physical
therapy team.
In The Lancet, the International Early Surgical Intensive
Care Unit (SICU) Optimal Mobilisation Score (SOMS)-
guided Mobilisation Research Initiative pushes this
coordination and communication approach even
further.4 Stefan Schaller and colleagues4 randomly
assigned 200 patients in five SICUs to either receive
standard care (n=96) or a specific targeted approach
to tracking physical therapy (n=104) with a facilitator
whose job was to make sure that therapy actually was
completed on a daily basis. However, unlike previous
studies, the facilitators—described as an experienced
medical doctor, registered nurse, or physical therapist
with ICU expertise—did not actually do the physical
therapy. The facilitators’ job was pure coordination and
communication. Patients received the attention of the
facilitator and the communication tool within 3 days of
intubation.
Their model of intervention is quite innovative. It
is potentially applicable to a wide range of inpatient
problems in addition to its effectiveness for ICU
mobilisation. The authors challenge clinicians and
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administrators to ask how often is the problem not
insufficient staff to do the best work for the patient,
but rather that existing staff efforts are too poorly
coordinated?
Amelie-Benoist/Bsip/Science Photo Library
The results of this communication and coordination
intervention were striking in this first trial, to our
knowledge, to explicitly target early rehabilitation in
mechanically ventilated patients in SICUs. Compared
with patients in the standard care (control) group, those
who were assigned to the SOMS-guided facilitator with
clear, team-set daily mobilisation targets (intervention See Articles page 1377
group) achieved higher levels of mobilisation (mean
achieved SOMS 2·2 [SD 1·0] in intervention group vs
1·5 [0·8] in control group, p<0·0001), had a shorter
duration in the SICU (median 7 days [IQR 5–12] in
intervention group vs 10 days [6–15] in control group,
p=0·0054), and were more functionally independent at
SICU discharge (mini-modified functional independence
measure score 8 [4–8] vs 5 [2–8]).4 These data are
consonant with the hypothesis that early mobilisation
might be particularly effective at preventing loss of
function in functionally independent patients.5 For this
prevention, early mobilisation needs to truly be early—
within the first few days of mechanical ventilation.
Further, prevention’s goal is the modest retention of
function, rather than ambitious rebuilding in patients
who have already lost some functioning abilities.
At the same time, a close reading of Schaller and
colleagues’ study4 reinforces how little is known
about the effects of early mobilisation on patient-
centred outcomes. Their findings at ICU discharge are
compelling. For some hospitals, the prospect of gaining
extra SICU bed capacity by early mobilisation might be
enough to prompt its use.
But for many, the goal of early mobilisation is not
simply reduced length of ICU stay, or even improved
functional status at hospital discharge. Many hope
(although it is unproven) that by jump-starting recovery,
early mobilisation for mechanically ventilated patients
in any ICU provides a durable benefit. One mechanism
of such durable benefit might be preventing patients
from a spiral of progressive complications, leading to
either nursing home placement or persistent critical
illness. However, it is also possible (and equally unproven)
that early mobilisation provides only a transient
1351
 Comment
improvement, readily equalled by patients not so
mobilised in the weeks after hospital discharge.
Far less is known about these later effects of early
mobilisation, whether provided by an additional
physical therapist or by more effective coordination and
communication of existing resources. Regrettably, the
International Early SOMS-guided Mobilisation Research
Initiative achieved only 42% (84 of 200 patients)
follow-up at 3 months. Such low figures at follow-
up are not uncommon in ICU RCTs, although not
universal.6 A full endorsement of early mobilisation
must wait for more data, even as many pragmatically
attempt early mobilisation based on the hope that
its effects on trajectory are durable. Large trials7 of
mobilisation in other patient groups provide caution to
making assumptions about its long-term benefit.
The future of early mobilisation research must move
beyond the ICU and must include randomised tests
of the hypothesis that early mobilisation provides
enduring improvements for patients. Additionally,
future research must go beyond the question of no
mobilisation or some mobilisation. At some point—
which will need more than 200 patients to be achieved—
the different strategies for mobilisation need to be
compared. These different strategies should include not
only different specific regimes of active exercise, but
also different approaches to integrate active exercise in
the core interdisciplinary teamwork of the ICU. Use of
these strategies will need use of all the tools of quality
improvement, both RCTs and registries. Patients who
are at particularly high risk for adverse outcomes of
mobilisation need to be identified, cognizant of the
non-significant difference in mortality seen in Schaller
Clear-lens extraction as a treatment for primary angle closure
See Articles page 1389 Glaucoma is a multifactorial spectrum of diseases
in which progressive optic nerve damage leading to
blindness occurs with raised intraocular pressure as
the main risk factor. The outflow of fluids through the
trabecular meshwork decreases when the iris moves
forward and comes into contact with it. This condition
is called “angle closure” and can lead to glaucoma
damage if intraocular pressure remains sufficiently
raised. When no other cause besides anatomical
predisposition is present for the iridotrabecular
1352
and colleagues’4 and other RCTs. Furthermore, an
understanding is needed of how early mobilisation
can be integrated into coherent programmes of before
ICU, in the ICU, and after ICU care to mitigate the post-
intensive care syndrome, maximising recovery for all
critically ill patients.
*Theodore J Iwashyna, Carol L Hodgson
Department of Internal Medicine, University of Michigan,
Ann Arbor, MI 48109, USA (TJI); Center for Clinical Management
Research, VA Ann Arbor Health System, Ann Arbor, MI, USA (TJI);
Australian and New Zealand Intensive Care Research Centre,
Department of Epidemiology and Preventive Medicine, Monash
University, Melbourne, VIC, Australia (TJI, CLH); and Department
of Physiotherapy, Alfred Hospital, Melbourne, VIC, Australia (CLH)
tiwashyn@umich.edu
The authors have proposed a large, international randomised clinical trial of
early mobility to follow patients to well after hospital discharge. This proposal
was submitted and under review before the invitation to write this Comment.
This work does not necessarily represent the views of the US Government or the
Department of Veterans Affairs.
1 Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and
occupational therapy in mechanically ventilated, critically ill patients:
a randomised controlled trial. Lancet 2009; 373: 1874–82.
2 Morris PE, Berry MJ, Files DC, et al. Standardized rehabilitation and hospital
length of stay among patients with acute respiratory failure: a randomized
clinical trial. JAMA 2016; 315: 2694–702.
3 Hodgson CL, Bailey M, Bellomo R, et al. A binational multicenter pilot
feasibility randomized controlled trial of early goal-directed mobilization in
the ICU. Crit Care Med 2016; 44: 1145–52.
4 Schaller SJ, Anstey M, Blobner M, et al, for the International Early SOMS-
guided Mobilization Research Initiative. Early, goal-directed mobilisation in
the surgical intensive care unit: a randomised controlled trial. Lancet 2016;
388: 1377–88.
5 Hodgson CL, Iwashyna TJ, Schweickert WD. All that work and no gain: what
should we do to restore physical function in our survivors?
Am J Respir Crit Care Med 2016; 193: 1071–72.
6 Needham DM, Dinglas VD, Bienvenu OJ, et al. One year outcomes in
patients with acute lung injury randomised to initial trophic or full enteral
feeding: prospective follow-up of EDEN randomised trial. BMJ 2013;
346: f1532.
7 The AVERT Trial Collaboration group. Efficacy and safety of very early
mobilisation within 24 h of stroke onset (AVERT): a randomised controlled
trial. Lancet 2015; 298: 46–55.
contact, the condition is classified as primary angle
closure, and if glaucomatous optic neuropathy
is present it is classified as primary angle-closure
glaucoma. The reported prevalence varies because of
heterogeneity in definitions of primary angle-closure
glaucoma and methods of angle assessment used in
different surveys.1 Even more common than primary
angle closure and primary angle-closure glaucoma is
primary open-angle glaucoma. These three disorders
have similarities, such as increasing prevalence after
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