Neurocrit Care (2017) 27:141–150
DOI 10.1007/s12028-016-0338-7
CURRENT CONCEPTS
Early Mobilization in the Neuro-ICU: How Far Can We Go?
Brian F. Olkowski1 • Syed Omar Shah2
Published online: 20 December 2016
Ó Springer Science+Business Media New York 2016
Abstract Immobility that is frequently encountered in the
intensive care unit (ICU) can lead to patient complications.
Early mobilization of patients in the ICU has been shown to
reduce the complications associated with critical illness;
however, early mobilization in the neurological intensive care
unit (NICU) presents a unique challenge for the multidisci-
plinary team. The early mobilization of patients with acute
neurologic injuries such as acute ischemic stroke, aneurysmal
subarachnoid hemorrhage, intracerebral hemorrhage, and
neurotrauma varies because of differing disease processes and
management. When developing an early mobility program in
the NICU, the following should be considered: the effect of
positional changes and exercise, the time from symptom onset
to the initiation of early mobilization, and the type and
intensity of the exercise prescribed.
Keywords Early mobilization
Rehabilitation

Acute ischemic stroke

Aneurysmal subarachnoid hemorrhage

Intracerebral hemorrhage
Neurotrauma
Introduction
Survivors of critical illness are often afflicted with the
cognitive, neuromuscular, psychological, and functional
deterioration known as post-intensive care syndrome [1–6].
& Brian F. Olkowski
bolkowski@capitalhealth.org
1 ventilation duration [19–22]. Early mobility programs in
Department of Rehabilitation, Capital Health Regional
Medical Center, Trenton, NJ, USA
2 care for patients can be lowered by as much as 15–30 %
Department of Neurosurgery, Thomas Jefferson University
and Division of Critical Care and Neurotrauma, Jefferson
Hospital for Neuroscience, Philadelphia, PA, USA
The immobility frequently encountered in the intensive
care unit (ICU) has been identified as one of the primary
causes of the complications experienced by ICU survivors
[7]. Fortunately, the early mobilization of patients in the
ICU has been shown to reduce the complications associ-
ated with critical illness [8, 9]. Early mobility programs
employ a multidisciplinary approach to increase patient
participation in upright activity and walking [10]. An
example of some of the features of an early mobility pro-
gram in the ICU is exhibited in Table 1. The majority of
early mobilization studies have been conducted on patients
with acute respiratory failure receiving mechanical venti-
lation in the ICU. Prior to participation, patients must
demonstrate physiologic and hemodynamic stability and
have adequate ventilation [11–16]. In addition, the inter-
ruption of sedation and management of delirium can
facilitate patient participation in an early mobility program
[11–16]. The benefits of the early mobilization of patients
with respiratory failure on mechanical ventilation have
included improved strength, physical function, and quality
of life while length of stay (LOS), cost, delirium, sedation,
and the duration of mechanical ventilation has been
reduced [11–18].
Can early mobilization be beneficial to patients with
acute neurologic injuries? Patients in the neurological ICU
(NICU) participating in an early mobility program con-
sisting of a progression from head of bed elevation to out-
of-bed activity and walking not only demonstrated
improved physical function but experienced a reduction in
pressure ulcers, infections, LOS, anxiety, and mechanical
the NICU have had a financial impact as well as the cost to
[20, 21]. Patients experiencing an acute stroke may also
benefit from early mobilization. AVERT (a very early
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142 Neurocrit Care (2017) 27:141–150

Table 1 Progressive early

Level 1 Level 2 Level 3 Level 4
mobility program for patients
with critical illness Location Bed Bed Bedside chair Room
EOB Standing Hallway
Activity HOB elevation Bed mobility Transfer to chair Walking
Bed mobility Sitting EOB Sitting OOB
Standing
Therapeutic exercise Passive ROM Passive ROM Active ROM Endurance
Active ROM Active ROM Weight shifting Dual task
Reaching
Functional training Bed mobility Bed mobility Transfers Gait balance
Positioning Posture Posture Posture
Balance Standing balance ADL
ADL ADL
Education Positioning Positioning Safety Safety
Family training Safety Assistive device Assistive device
Family training Family training Family training
Goal Upright tolerance Sitting balance OOB activity Strength
Standing balance Gait balance
Endurance
HOB head of bed, EOB edge of bed, OOB out of bed, ROM range of motion, ADL activities of daily living

rehabilitation trial) and VERITAS (very early rehabilita-
tion or intensive telemetry after stroke) focused on
increasing the frequency of out-of-bed activity and walking
within 24 h of the onset of symptoms in patients with acute
stroke [23–28]. The results were encouraging as the early
mobilization of patients within the first 24 h of stroke
symptom onset improved quality of life, motor function,
walking, and activities of daily living [23–28].
Why has there been a reluctance to utilize early mobility
programs when caring for patients with acute neurologic
injuries in the NICU? The success of AVERT led to its
expansion into a multinational randomized controlled trial,
the largest early mobilization trial conducted on patients
with acute stroke [29]. The study included over 2000
patients from five countries, but the results were unex-
pected as patients receiving early mobilization within 24 h
of stroke symptom onset were more likely to have an
unfavorable outcome (moderate or severe disability, or
death) at 3 months compared to patients receiving standard
care [29]. Early mobilization did not reduce immobility-
related complications or accelerate walking recovery [29].
Since the majority of clinical practice guidelines recom-
mended the early mobilization of patients after acute
stroke, the results of AVERT left clinicians questioning
whether early mobilization within the first 24 h of symp-
tom onset should be considered after acute stroke [30–33].
Some clinical practice guidelines have already considered
the new evidence and now discourage very early, high-
intensity early mobilization in the first 24 h after acute
stroke [34]. In addition, it has been difficult for clinicians to
generalize the results of the early mobilization studies
conducted on patients with acute respiratory failure
receiving mechanical ventilation to patients with a primary
neurologic injury in the NICU because of the differing
patient presentations and management.
What is the role of early mobilization in the NICU? The
purpose of any early mobility program is to reduce the
complications and disability associated with ICU admis-
sion by increasing patient participation in upright activity
closer to the onset of critical illness. The early mobilization
of patients in the NICU presents a unique challenge for the
multidisciplinary team. The transition of these patients to
more progressively upright positions and increased activi-
ties such as walking can be physically demanding on NICU
staff because of the disability that typically results from a
primary neurologic injury. More importantly, the early
mobilization of patients in the NICU has the potential to be
detrimental to long-term recovery. We will consider the
following when exploring the potential benefits of an early
mobility program for patients with various acute neuro-
logic injuries receiving care in the NICU:
1. The effect of positional changes and exercise on
physiologic and hemodynamic stability.
2. The time from symptom onset to the initiation of early
mobilization.
3. The type and intensity of the exercise prescribed during
early mobilization.

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4. The impact of medical and surgical management on
early mobilization.
We hope this review will stimulate clinicians to evaluate
their early mobilization practices in the NICU. In addition,
we hope clinicians will explore new areas that will advance
rehabilitation in the NICU with the goal of reducing the
complications and disability that afflict the survivors of
neurological critical illness.
Acute Ischemic Stroke
The guidelines for the early management of patients with
acute ischemic stroke (AIS) recommend the early mobi-
lization of less severely affected patients to prevent
complications [35]. The criteria for participation and the
recommended time from AIS symptom onset to the initi-
ation of early mobilization are not yet defined. During the
initial stages of early mobilization, trials of passive head of
bed elevation are frequently used to ensure that patients
achieve hemodynamic and physiologic stability in upright
positions before they are permitted to participate in out-of-
bed and walking activities [10]. Head position within the
first 24 h after AIS may have an impact on neurologic
recovery. Several studies have suggested that a higher head
of bed position within the first 24 h after AIS may reduce
cerebral blood flow on the affected hemisphere raising the
concern that reduced cerebral blood flow could diminish
cerebral perfusion when ischemic brain tissue may be most
vulnerable [36–38]. The potential long-term outcomes and
clinical significance of increased blood flow observed with
flat head positioning compared to head elevation within the
first 24 h after AIS are currently under investigation in both
the head position in stroke trial (HeadPoST) and cerebral
hemodynamics and orthostatic response to upright posture
in acute ischemic stroke (CHORUS) study [39, 40]. The
results of both studies should be considered when devel-
oping an early mobility program for patients with AIS
since frequent positional changes and head elevation are
critical components of an early mobility program.
The initiation of early mobilization within the first 24 h
of symptom onset after AIS may also have an impact on
neurologic recovery. AKEMIS (Akershus early mobiliza-
tion in stroke) was conducted to determine whether there
was a benefit to patient participation in out-of-bed activity
within 24 h of stroke symptom onset compared to mobi-
lization between 24 and 48 h [41]. Unlike in AVERT and
VERTIAS, the dose of early mobilization in AKEMIS was
not doubled. Although not significant, patients receiving
early mobilization within 24 h of symptom onset experi-
enced increased disability, mortality, and dependency
compared to patients receiving mobilization between 24 and
48 h [41]. The investigators could not identify a reduction in
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immobility-related complications such as venous throm-
boembolism, pulmonary embolism, pneumonia, urinary
tract infection, and falls [41]. When the dose of early
mobilization was doubled in AVERT, patients receiving a
higher intensity of early mobilization within the first 24 h of
symptom onset after AIS were more likely to have an
unfavorable outcome (moderate or severe disability, or
death) at 3 months compared to patients receiving standard
care [29]. Animal models also suggest that the time to ini-
tiation of training after induced AIS could be detrimental to
recovery if initiated within the first 24 h. The initiation of
training within 24 h after induced AIS resulted in worse
cognitive function, neurologic function, and recovery of
limb function compared to the initiation of training between
1 and 5 days after induced AIS [42].
With evidence suggesting that the timing of the initia-
tion of early mobilization may influence outcomes, early
mobilization of patients within 24 h of AIS symptom onset
should be approached cautiously and on a case by case
basis with careful monitoring of neurologic presentation
and hemodynamic and physiologic response to positional
changes and exercise. If the results from HeadPoST and
CHORUS determine that head of bed elevation within the
first 24 h after symptom onset is detrimental to recovery, it
may not be advantageous to move forward with further
early mobilization trials that commence within the first
24 h after AIS. In addition, there does not appear to be a
benefit to increasing the dose of mobilization within the
first 24 h after AIS. AVERT almost tripled the dose of
early mobilization which, along with initiation of mobi-
lization closer to the onset of symptoms, ultimately proved
detrimental to recovery [29]. Future research may include
early mobilization at a lower intensity within the first 24 h
after AIS. Mobilization after 24 h appears safer, but careful
monitoring of neurologic presentation and hemodynamic
and physiologic response to positional changes and exer-
cise should be conducted. Recommendations for the early
mobilization of patients after AIS are summarized in
Table 2.
The hemodynamic response of increasing blood pres-
sure after AIS may protect vulnerable brain tissue by
improving perfusion to the penumbra. The maintenance of
arterial hypertension during the verticalization of patients
after AIS can be challenging. Several studies have utilized
a tilt table without active patient participation and deter-
mined that passive upright activity after AIS frequently
results in orthostatic hypotension (OH) [43, 44]. Studies
conducted on early mobilization after AIS provide few
details on the frequency and timing of blood pressure
monitoring during early mobilization, the blood pressure
ranges used or how blood pressure was managed
[27, 29, 41]. In AVERT, early mobilization was terminated
if blood pressure in an upright position dropped more than
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Table 2 Recommendations and considerations for early mobilization in the NICU

Diagnosis Time to initiation Intensity Level of Consideration Solution
evidence*

Acute 24 h after symptom No benefit to increased 2 HOB elevation HeadPoST/CHORUS to determine

ischemic onset intensity during 24–48 h within outcomes of head of bed elevation
stroke after symptom onset 24 h of
symptom
onset
Maintain Close BP monitoring before, during and
arterial after mobilization. Consider
hypertension mobilization if patient stable and not
actively titrating parenteral
vasopressors or antihypertensives
Aneurysmal 24–48 h after After aneurysm treatment, 3 EVD Ensure EVD securely placed and ICP
Subarachnoid aneurysm HOB elevation within levels consistently below 20 mmHg
hemorrhage treatment 24–48 h and mobilization Asymptomatic If stable neurologic exam, should not
out of bed after 48 h vasospasm preclude mobilization
Single ICP ICP spike related to an acceptable reason
spike (i.e., during bowel movement, needle
insertion) should not preclude
mobilization
Spontaneous 24 h after stable ICH Unknown 3 BP fluctuations Ensure proper control of BP with oral or
Intracerebral volume continuous medications prior to
hemorrhage mobilization
Single ICP ICP spike related to an acceptable reason
spike (i.e., during bowel movement, needle
insertion, etc.) should not preclude
mobilization
Spinal cord 24 h after spine Unknown 5 Orthostatic Close BP monitoring before, during and
injury stabilization hypotension after mobilization. Consider
mobilization if patient stable and not
actively titrating vasopressors
Traumatic 24 h of Unknown 5 Single ICP ICP spike related to an acceptable reason
brain injury stable hemorrhage spike (i.e., during bowel movement, needle
volume insertion, etc.) should not preclude
mobilization
* Oxford Centre for Evidence-Based Medicine Levels of Evidence Working Group. ‘‘The Oxford 2011 Levels of Evidence.’’ http://www.cebm.
net/ocebm-levels-of-evidence
NICU neurological intensive care unit, HOB head of bed, BP blood pressure, EVD external ventricular drain, ICP intracranial pressure, ICH
intracerebral hemorrhage

30 mmHg, but they did not use a minimal blood pressure
level [29]. Medications such as vasopressors can be pre-
scribed after AIS to increase arterial blood pressure and
improve cerebral blood flow [10]. The use of low-dose
vasopressors in conjunction with serial monitoring of blood
pressure may allow more patients to remain within an
appropriate blood pressure range during early mobilization.
Future early mobilization studies should consider using
blood pressure ranges consistent with evidence-based
clinical guidelines. In addition, early mobilization studies
in patients with AIS have not been conducted in the NICU.
The NICU may be an appropriate setting for an early
mobilization study because the NICU is capable of close
monitoring and management of blood pressure during the
first 2 days after AIS when brain tissue is most vulnerable.
The guidelines for the early management for patients
with AIS recommend intravenous fibrinolytic therapy and
mechanical thrombectomy in the setting of early ischemic
changes [10]. A small study examining the safety of
mobilizing patients within 24 h of the administration of
recombinant tissue plasminogen activator (rt-PA) identified
minimal adverse events during early mobilization [45].
Although AVERT indicated an unfavorable outcome
(moderate or severe disability, or death) for patients
receiving early mobilization at a higher intensity within the
first 24 h of symptom onset after AIS, the outcomes were
no different for those receiving recombinant tissue plas-
minogen activator (rt-PA) compared to patients that did not
receive treatment [29]. There have been no studies exam-
ining the effect of early mobilization after mechanical

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thrombectomy. Patients with improved vessel perfusion or
recanalization after the administration of rt-PA or
mechanical thrombectomy may be better candidates to
participate in an early mobilization program. Brain tissue
perfusion may be improved or restored after treatment
which may diminish the potential negative effects of head
of bed elevation and higher doses of mobilization that
resulted in poor outcomes in previous studies. Further
research is needed to determine the benefit of early mobi-
lization after rt-PA and mechanical thrombectomy.
Aneurysmal Subarachnoid Hemorrhage
Survivors of aneurysmal subarachnoid hemorrhage (aSAH)
are faced with a complicated recovery which includes early
aneurysm repair, prolonged monitoring in the intensive
care unit (ICU) and treatment focusing on the prevention of
complications and secondary brain damage. Patients may
be prescribed bed rest or may be forced to limit their
mobility due to continuous electroencephalography, tran-
scranial Doppler (TCD) ultrasonography, or an external
ventricular drain (EVD). The guidelines for the manage-
ment of patients with aSAH do not address when or if it is
safe to mobilize patients after aneurysm treatment [46, 47].
Despite improvements in the mortality rates of patients
with poor-grade aSAH from the original Hunt Hess num-
bers to more recent statistics after the institution of
neurocritical care units, the mobilization of these patients
and how it may affect outcomes have not been adequately
addressed [48, 49]. A recent Cochrane Review was unable
to provide an accurate meta-analysis between early versus
late ambulation in patients with aSAH due to a lack of
randomized control trials [50].
There is a significant potential for immobility after
aSAH which places these patients at a high risk for cog-
nitive, neuromuscular, psychological, and functional
deterioration. A few small trials have shown that the early
mobilization of patients with aSAH can be performed
safely and with minimal serious adverse events [51–53].
Early mobilization after aSAH may decrease hospital LOS
and the amount of time spend in bed while reducing dis-
ability in poor-grade patients [54, 55]. Head of bed
elevation can begin the first day after aneurysm treatment
and out-of-bed activity typically begins on the second day
but may be delayed in patients with a poor-grade aSAH
[51, 53–57]. Patients were not allowed to progress with
early mobilization if there was increased ICP
(>15–20 mmHg), inadequate MAP (<80 mmHg) or if
there was evidence of symptomatic vasospasm or severe
vasospasm on computed tomography, digital subtraction
angiography and/or TCD ultrasonography [51, 53–55, 57].
In addition, the presence of an EVD did not preclude
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patients from being mobilized out of bed and participating
in walking activities [51, 53–55, 57]. The early mobiliza-
tion of patients with an EVD has been observed in other
studies [20], but it has not become a standard practice to
mobilize patients with an EVD in the NICU. Recommen-
dations for the early mobilization of patients after aSAH
are summarized in Table 2.
Historically, a barrier to mobilizing patients with an
aSAH has been the perceived fear of the development of
cerebral vasospasm and delayed cerebral ischemia [51]. In
addition, there may be an assumption that increased
activity can adversely affect intracranial pressure (ICP)
and/or arterial blood pressure, thereby reducing cerebral
perfusion pressure (CPP) and leading to secondary brain
injury [51]. These perceptions may not be true as several
studies have demonstrated that head of bed position as well
as passive range of motion did not change cerebrovascular
hemodynamics [58, 59]. A recent study found less clinical
vasospasm and a greater than 30 % risk reduction for
severe vasospasm in patients participating in early ambu-
lation [57]. Similar results in a retrospective study
determined that early exercise following aneurysm repair
reduced symptomatic vasospasm by 42 % [60]. A possible
explanation is that aggressive cerebrospinal fluid (CSF)
drainage along with mobilization led to less sedimentation
of blood products allowing less clot burden and thus less
vasospasm [57], similar to the ‘‘head shaking’’ and cister-
nal irrigation theory which reduced cerebral vasospasm in
multiple Japanese studies, [61–63].
Patients with aSAH are typically admitted to the hospital
for several weeks resulting in a longer LOS and period of
immobilization compared to patients with other acute
neurologic injuries. Although there is a lack of randomized
control trials examining the effectiveness of early mobi-
lization after aSAH, it appears that early mobilization can
be accomplished safely with minimal adverse events in
patients with a stable or improving neurologic presentation.
Due to the high level of monitoring in the NICU, adverse
events resulting from early mobilization can be quickly
identified and resolved. Future randomized control trials
are needed to examine the benefits of early mobilization
after aSAH and should identify the type and intensity of the
activities performed during early mobilization.
Spontaneous Intracerebral Hemorrhage
The guidelines for the management of patients with spon-
taneous intracerebral hemorrhage (ICH) recommend that
rehabilitation commence as early as possible [64].
Although the guidelines do not specifically recommend
‘‘early mobilization,’’ it is consistent with the other stroke
clinical practice guidelines in that it does not define when
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rehabilitation should begin and the type and intensity of the
activity. Most studies that have examined the effect of
early mobilization after acute stroke have excluded patients
admitted to the ICU resulting in a small number of patients
with ICH meeting inclusion criteria [27, 29, 41]. Only one
study has specifically examined the early mobilization of
patients with spontaneous ICH [65]. Patients in the early
mobilization group participated in functional training
which focused on out-of-bed activity and activities of daily
living, similar to other early mobilization studies [65].
Patients with spontaneous ICH receiving early mobiliza-
tion within 48 h of admission were compared to patients
beginning rehabilitation 7 days after ICH. Patients receiv-
ing early mobilization were more likely to be alive at
6 months and have a shorter hospital LOS, higher quality
of life and greater independence with activities of daily
living [65].
Since the management of ICH differs than that of other
diagnoses, it is important to develop an early mobilization
program specific to this patient population. The early
management of blood pressure after spontaneous ICH
focuses on monitoring the volume of the hemorrhage and
maintaining systolic blood pressure (SBP) below
140 mmHg [64]. Early mobilization should not be initiated
until the hemorrhage volume has stabilized for at least
24 h. Since upright activity and exercise may result in
blood pressure fluctuations, blood pressure monitoring
should be completed before, during and after mobilization.
Patients may experience an increase in blood pressure with
exercise, and blood pressure should be monitored to ensure
that SBP does not increase above 140 mmHg during
mobilization. Likewise, the early management of patients
after spontaneous ICH focuses on preventing increased ICP
[64]. Head of bed elevation and active exercise in bed have
been shown to slightly lower ICP in patients receiving
physical therapy in the NICU [66]. Early mobilization
should not be initiated on patients with an ICP greater than
20 mmHg. Further research is needed to identify the
potential benefits of the early mobilization of patients after
spontaneous ICH. Recommendations for the early mobi-
lization of patients after spontaneous ICH are summarized
in Table 2.
Neurotrauma
The guidelines for the acute management of patients with
spinal cord injury (SCI) recommend early rehabilitation
and patient participation in out-of-bed activity as soon as
medical and spinal stability are achieved [67]. Mean arte-
rial pressure (MAP) is typically maintained at a level
greater than 85–90 mmHg for the first 7 days to ensure
perfusion of the damaged spinal cord [68]. Patients with a
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Neurocrit Care (2017) 27:141–150
higher MAP in the acute stages after SCI correlated with
better neurologic recovery, and the strongest correlation
was within the first 2–3 days [69]. Unfortunately, patients
often experience orthostatic hypotension (OH) after acute
SCI which may be caused by a loss of sympathetic-medi-
ated vascular tone, altered baroreflex function, the lack of
skeletal muscle pumping activity, cardiovascular decondi-
tioning and/or altered salt and water balance [70]. Patients
experiencing more severe injuries have a higher incidence
of OH and are more likely to require vasopressors to
maintain MAP and encourage spinal cord perfusion [71].
The effect of early mobilization on patients with acute
SCI is not known. Some of the perceived benefits include a
reduction in the complications associated with immobility,
such as pneumonia, bed sores and venous thromboem-
bolism, and earlier admission to inpatient rehabilitation
which has been shown to improve functional outcomes
[72]. Early mobilization after acute SCI can be challenging
due to OH as patients often experience OH during the
transition to and with sustained upright activity. Several
interventions have been used to reduce the incidence of OH
[73]. Non-pharmacologic interventions such as lower-ex-
tremity graduated compression stockings and abdominal
binders have been used, but there is little evidence to
support their efficacy [74]. Although used after the acute
phase of SCI, functional electrical stimulation has been
shown to reduce OH [71]. Further exploration of electrical
stimulation in the acute phases of SCI and other interven-
tions which diminish OH may allow for earlier and more
frequent mobilization while maintaining MAP at recom-
mended levels.
The early mobilization of patients after severe traumatic
brain injury (TBI) has not been studied extensively. Similar
to spontaneous ICH, the management of severe TBI
includes the monitoring of ICP and neurologic presentation
in the NICU with possibility of surgical decompression in
severe cases [75]. An observational study determined that
the early rehabilitation severe TBI commenced greater than
1 week after injury on average and consisted of passive
interventions that included frequent positional changes
[76]. Similarly, another study reported that rehabilitation
using a tilt table to increase the time patients spent in an
upright position commenced greater than a week after
injury on average [77]. The mobilization of patients with
severe TBI appears to begin later than patients with an
acute stroke. In addition, a more passive verticalization is
utilized initially possibly due to a disorder of consciousness
and/or the patient’s inability to follow commands. At this
time, it is not known whether patients may benefit from
earlier interventions after severe TBI. The effect of early
mobilization on ICP, complications, and long-term out-
comes may be beneficial to the management of patients
with severe TBI. Recommendations for the early
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Table 3 Safety checklist specific to early mobilization in the NICU

Yes No N/A Inclusion criteria

h h h If there is an EVD, is the EVD closed and secure for patient mobilization?
h h h Have ICPs been well controlled for 24 h with no administration of mannitol or hypertonic saline?
h h h Is there no active titration of parenteral vasopressors or antihypertensives?
h h h Is the CAM-ICU negative for delirium?
h h h Does the patient have a stable neurologic exam?
h h h If patient has an AIS, has it been 24 h after the onset of symptoms?
h h h If patient has an aSAH, has the aneurysm been treated?
h h h If patient has a spontaneous ICH, has the hemorrhage volume been stable for 24 h?
If all above questions are answered ‘‘Yes’’ or ‘‘N/A,’’ proceed with early mobilization
NICU neurological intensive care unit, EVD external ventricular drain, ICP intracranial pressure, CAM-ICU confusion assessment method for
the intensive care unit, AIS acute ischemic stroke, aSAH aneurysmal subarachnoid hemorrhage, ICH intracerebral hemorrhage

mobilization of patients after SCI and TBI are summarized
in Table 2.
Discussion
Early mobility programs have been shown to reduce the
complications associated with immobility in the ICU.
Although most studies have been conducted on patients
without a primary neurologic injury, recent studies have
begun to identify patients that may benefit from early
mobilization in the NICU. As early mobility programs
become more common in the NICU, it is imperative that
clinicians become aware of the potential harm that may
result from the early mobilization of patients with acute
neurologic injuries. Patient diagnosis, the time to initiation
of early mobilization, the effect of positional changes and
exercise and the type and dose of activity need careful
consideration when implementing an early mobility pro-
gram in the NICU (Table 2). The early mobilization of
patients with acute neurologic injuries may not be indicated
due to physiologic and hemodynamic instability, similar to
critically ill patients on mechanical ventilation [78]. In
addition, a safety checklist that includes contraindications
to patient mobilization in the NICU is suggested in
Table 3.
The establishment of an early mobility program in the
NICU may prove to be challenging. Fortunately, several
strategies have been shown to support the implementation
and maintenance of early mobilization practices. The
ABCDE bundle is a coordinated effort between multiple
disciplines aimed at reducing sedation, immobility and the
development of delirium, all of which harm patients with
critical illness [79]. Although it has been recommended to
reduce sedation in critically ill patients to prevent delirium
and improve participation in early mobilization, sedation in
the NICU has indications specific to patients with acute
neurologic injuries [80]. Sedation in the NICU may be
indicated to reduce cerebral metabolic demand, improve
brain tolerance to ischemia and control seizures, tempera-
ture and ICP [81]. These ‘‘neuro-specific’’ indications for
sedation may pose a barrier for the recommended daily
sedation interruptions that may increase patient participa-
tion in early mobility programs. Effective communication
among caregivers and coordination of care during daily
multidisciplinary rounds may facilitate daily sedation
interruptions and prevent delirium, ultimately facilitating
early mobilization in the NICU [82, 83].
Early mobilization in the NICU presents unique chal-
lenges for the multidisciplinary team. Although more
research is needed, some evidence demonstrates that early
mobilization in the NICU can be done safely and improve
patient’s outcomes. We recommend that clinicians use the
existing evidence as a guide in making informed decisions
on when to mobilize patients in the NICU. We encourage
you to be receptive to rehabilitation in the NICU and
explore new ways to reduce immobility. Evaluate each
patient for their eligibility to participate in an early
mobility program and develop a process in your NICU, so
patients can receive safe and effective early mobilization
when indicated.
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