Chronic disorders of consciousness (cDoC) resulting from severe traumatic brain injury (sTBI) are associated with significant challenges in treatment and recovery. This review explores multimodal interventions aimed at improving patient outcomes.

A systematic review was conducted on peer-reviewed studies from PubMed and Google Scholar published between 2000 and 2023. The review included clinical trials, observational studies, and case series that assessed interventions for improving consciousness and cognitive function in patients with cDoC following sTBI. Interventions considered included pharmacological treatments, non-invasive neuromodulation, rehabilitation therapies, and traditional medicine approaches.

The review identifies several promising interventions. Hyperbaric oxygen therapy (HBOT), when combined with physical rehabilitation and non-invasive brain stimulation techniques like transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), has shown positive effects on consciousness and cognitive recovery. Non-invasive neuromodulation techniques have been linked to improvements in cortical activity and consciousness, with taVNS emerging as a novel approach. Additionally, traditional Chinese medicine, particularly herbal therapies, has demonstrated complementary benefits when integrated with modern rehabilitation methods. Personalized treatment strategies based on clinical characteristics, biomarkers, and genetic data were found to enhance recovery. Notably, integrating these modalities into personalized care protocols has shown enhanced efficacy, suggesting that individualized approaches are critical for improving outcomes.

Multimodal therapies show promise in enhancing recovery in cDoC patients after sTBI, but further research is needed to optimize treatment protocols and standardize clinical practices. The integration of traditional and modern therapies represents a potentially effective strategy for improving patient outcomes.

Patients with coronary artery disease (CAD) can improve quality of life by undergoing coronary artery bypass graft (CABG), but they may face various complications. Early mobilization can help prevent these complications. This study aimed to evaluate the effects of two early mobilization protocols on pain and hemodynamic outcomes in patients who had CABG surgery.

This was a randomized, blinded clinical trial with a three-arm parallel design, conducted on 105 patients who underwent CABG at Shahid Madani hospital in Tabriz. The patients were randomly assigned to three groups: control, first intervention, and second intervention. The control group received standard care, while two intervention groups received early mobilization based on passive and active range of motion (ROM) activities and early mobilization based on deep breathing exercises respectively. Data were collected using a questionnaire that measured pain intensity using a facial pain scale and hemodynamic indicators using a monitor device. Data analysis was performed using SPSS version 24 software and descriptive and inferential statistics methods.

According to the study, the second intervention group is more effective than the first intervention group. The results indicated that in both morning and evening shifts, the mean of systolic blood pressure (SBP) increased significantly in three groups. Also, the mean of diastolic blood pressure (DBP) increased significantly in both shifts in intervention group 1 and control. The mean of DBP decreased (MD=-26.0, 95% CI: -5.6 to -1.2; P=0.003) significantly among intervention group 2 compared to control group in the evening. The results also indicated that the mean of heart rate (HR) raised significantly in both shifts in all three groups. In the morning, there was a significant difference between intervention group 2 and 1 compared to control. The mean of arterial oxygen saturation was a significant difference between intervention group 2 and intervention group 1 and control group in the both shifts. The mean of pain decreased significantly in the morning in two intervention groups. Similarly, in the evening, the mean of pain decreased significantly in intervention group 1, and intervention group 2. Both in the morning and evening, there was a significant difference between intervention group 2 and intervention group 1 (P<0.001).

This study provides valuable insights into the effects of early mobilization interventions on patients after CABG, but more research is needed to determine the optimal timing and intensity of mobilization protocols for patients after CABG and to explore the long-term effects and cost-effectiveness of these interventions.

Critical illness significantly impacts the well-being of patients and families. Previous studies show that family members are willing to participate in patient care. Involving families in early mobility interventions may contribute to improved recovery and positive outcomes for patients and families.

In this scoping review, we investigated early mobility interventions for critically ill patients evaluated in randomized controlled trials and the extent to which family engagement in those interventions are reported in the literature.

In this scoping review of reviews, EMBASE, CINAHL, PubMed and Cochrane Central databases were searched in October 2019 and updated in February 2022. Systematic reviews were included and assessed using A MeaSurement Tool to Assess Systematic Reviews (AMSTAR) 2. Data were synthesized using a narrative approach. PRISMA-ScR guidelines were adhered to for reporting.

Thirty-three reviews were included which described a range of early mobility interventions for critically ill patients; none explicitly mentioned family engagement. Almost half of the reviews were of low or critically low quality. Insufficient detail of early mobility interventions prompted information to be extracted from the primary studies.

There are a range of early mobility interventions for critically ill patients but few involve families. Given the positive outcomes of family participation, and family willingness to participate in care, there is a need to explore the feasibility and acceptability of family participation in early mobility interventions.

Family engagement in early mobility interventions for critically ill patients should be encouraged and supported. How to best support family members and clinicians in enacting family involvement in early mobility requires further investigation.

Many ICUs worldwide are striving to integrate early mobilization as part of critical care rehabilitation. However, ICU nurses, who are essential contributors to the early mobilization of critically ill patients, still lack comprehensive surveys assessing their knowledge, beliefs, and practices regarding the early mobilization of mechanically ventilated patients.

To analyse the knowledge, attitudes, and practices of intensive care unit (ICU) nurses regarding the early mobilization of mechanically ventilated patients and to explore the effects of these practices.

A multicentre cross-sectional study. ICU nurses in five tertiary hospitals in Zhejiang Province, China, were selected by convenience sampling and invited to complete an online questionnaire between 1 June 2021 and 15 June 2021. Sociodemographic data and the knowledge, attitudes, and practices of ICU nurses regarding early mobilization.

A total of 296 valid questionnaires were collected, for a response rate of approximately 77.5%. The average scores for knowledge, attitudes, and practices of ICU nurses regarding the early mobilization of mechanically ventilated patients were 42.7 ± 7.4, 34.3 ± 6.5, and 47.1 ± 6.5, respectively, which were good scores. Quantile regressions showed that at the 25% and 50% quartiles, increases in knowledge and attitude scores resulted in increases in practice scores (p < .001); however, at the 75% quartile, increases in knowledge scores did not result in practice score increases (t = 0.000, p = .999); moreover, there was still a 0.5-point increase in practice scores per 1-point increase in attitude scores (t = 0.500, p < .001).

The knowledge, attitudes, and self-reported practices of ICU nurses were good, although there is room for improvement. Considering that the influence of attitudes on practice improvement is more important than knowledge, ICU managers should promote knowledge transformation, strengthen attitudes, and adopt comprehensive measures to promote the early mobilization of mechanically ventilated patients in the ICU.

To optimize the early mobilization of mechanically ventilated patients in the ICU, introducing multipronged support strategies based on the knowledge and attitudes of ICU nurses is recommended to promote the implementation of such practices.

The objectives of this study were to determine the effect of COVID-19 on physical therapy (PT) mobilization of trauma patients and to determine if mobilization affected patient course in the ICU. This retrospective study included patients who were admitted to the ICU of a level II trauma center. The patients were divided into two groups, i.e., those admitted before (n = 378) and after (n = 499) 1 April 2020 when Georgia's COVID-19 shelter-in-place order was mandated. The two groups were contrasted on nominal and ratio variables using Chi-square and Student's t-tests. A secondary analysis focused specifically on the after-COVID patients examined the extent to which mobilization (n = 328) or lack of mobilization (n = 171) influenced ICU outcomes (e.g., mortality, readmission). The two groups were contrasted on nominal and ratio variables using Chi-square and Student's t-tests. The after-COVID patients had higher injury severity as a greater proportion was classified as severely injured (i.e., >15 on Injury Severity Score) compared to the before-COVID patients. After-COVID patients also had a greater cumulative number of comorbidities and experienced greater complications in the ICU. Despite this, there was no difference between patients in receiving a PT consultation or days to mobilization. Within the after-COVID cohort, those who were mobilized were older, had greater Glasgow Coma Scale scores, had longer total hospital days, and had a lesser mortality rate, and a higher proportion were female. Despite shifting patient injury attributes post-COVID-19, a communicable disease, mobilization care remained consistent and effective.

A prolonged stay in the intensive care (ICU) is associated with physical function decline following cardiac surgery. To predict physical function decline after cardiac surgery, it may be important to evaluate physical function in the ICU.

This study aimed to determine that physical function examination at ICU discharge was independently associated with physical functional decline at hospital discharge in elderly patients who had undergone cardiac surgery and prolonged the ICU stay.

We assessed physical function before and after cardiac surgery in elderly patients who had spent ≥72 h in the ICU in this retrospective cohort study using the short physical performance battery (SPPB). At hospital discharge, a decrease of at least 1 point on the SPPB was considered a postoperative physical functional decline. Postoperative physical functional decline at hospital discharge was predicted using multiple logistic regression.

We revealed postoperative physical functional deterioration in 28.0% of patients who spent ≥72 h in the ICU following cardiac surgery. The Medical Research Council sum score (MRC-SS) (OR: 0.96, 95% CI: 0.82-0.99) and mechanical ventilation days (OR: 1.27, 95% CI: 1.01-1.64) were independently associated with physical functional decline at hospital discharge.

Physical function at ICU discharge and mechanical ventilation days were predictors of postoperative physical functional decline at hospital discharge in patients. MRC-SS was more accurate in predicting postoperative physical functional decline at hospital discharge when performed at the time of ICU discharge.

An increasing number of patients are receiving rehabilitation after stroke. But the impact of intensive rehabilitation on the long-term prognosis of patients with stroke remains to be elucidated. The purpose of this study was to identify the impact of intensive rehabilitation on the long-term prognosis of patients with stroke using data from the National Health Insurance Service database. This is a register-based, retrospective cohort study. Using data from the National Health Insurance Service database, we included the patients who received rehabilitation for stroke from 2006 to 2013. Of the 14,984 patients diagnosed with stroke, 2483 died within 1 year, and 2866 did not receive rehabilitation; hence, they were also excluded. The final sample included 9635 (49.2% men, 50.8% women) patients. After correcting for covariates, the Cox model was used to evaluate the effects of physical therapy (PT) and occupational therapy (OT) on survival. We estimated the independent contribution of each factor to the risk of death from the initiation of rehabilitation. Significant differences in mortality were observed according to age, Charlson comorbidity index (CCI), income level, and stroke type. Patients with stroke who received both PT and OT had a better long-term prognosis than those who received either treatment alone. Therapy performed by a physical therapist with more than 120 hours of training effectively improved the patients' long-term prognosis. Intensive PT and OT will help improve the long-term prognosis of patients with stroke. This study emphasizes the importance of intensive rehabilitation in these patients.

There are limited scientific data regarding the impact of exercise after breast augmentation surgery. Recommendations range from a few weeks to a few months of physical activity avoidance. To decide whether early exercise after breast augmentation is safe, a prospective randomized trial was designed to measure complications, scar quality, and patient-reported outcomes in this setting.

The present study was a randomized controlled trial to investigate the effects of early exercise (1 week after surgery) on postoperative complications, scar quality, and patient-reported outcome (BREAST-Q). All women undergoing primary breast augmentation surgery in the authors' institution were randomized to either standard restrictions or exercise. The three primary outcomes measured were the presence of a complication and reoperation, scar quality, and patient-reported outcome.

A total of 225 participants were included in the final analysis. No differences were found among the groups for age (p = 0.66), implant size (p = 0.56), or implant pocket (p = 0.29); complication rates did not change between the control (7.5 percent) and exercise groups (6.9 percent). When assessed 12 months after surgery, the scar quality was comparable between the groups (29.9 control and 29.6 exercise, p = 0.204). Intervention groups (exercise) performed better on the BREAST-Q Augmentation Module: Satisfaction with Outcome score (66.3 control and 83.4 exercise, p < 0.01).

Early exercise following primary breast augmentation does not increase complication or reoperation rates or cause a reduction in scar quality after 1 year. In addition, a patient-reported outcome showed improvement in the exercise groups.

Therapeutic, II.

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.

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.

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.

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.

How to cite this article: Daptardar AA. Quest of Knowledge and Perceived Barriers toward Early Mobilization of Critically Ill Patients in Intensive Care Unit: A Continuing Journey! Indian J Crit Care Med 2021;25(5):489-490.

Existing algorithms do not allow for setting up finely tuned progression or intensity for exercise training in intensive care units (ICUs).

We aimed to assess the feasibility and tolerance of a very early exercise program tailored by using decisional algorithm that integrated both progression and intensity.

Open-label pilot study.

ICU.

Thirty adults hospitalized in ICU.

Once a day, patients performed manual range of motion, cycloergometry, and functional training exercises. The progression and intensity of training were standardized by using the constructed algorithm. The main outcome, discomfort on a 0-100 Visual Analog Scale, was assessed before and after each exercise session. Secondary outcomes were muscle strength, ICU length of stay and adverse events related to exercise.

Overall, 125 exercise sessions were performed. Discomfort during exercise sessions decreased significantly by the fifth session (P=0.049). Early exercise sessions were feasible and did not produce major adverse events.

We confirmed the safety and feasibility of very early exercise programs in ICUs. Early exercise tailored by using a decisional algorithm helps relieve the discomfort of ICU patients.

In everyday practice, the use of decisional algorithms should be encouraged to initiate and standardize early exercise in ICUs.

Prolonged hospitalization and immobility of critical care patients elevates the risk of long-term physical and cognitive impairments. However, the therapeutic effects of early mobilization have been difficult to interpret due to variations in study populations, interventions, and outcome measures. This systematic review and meta-analysis aims to assess the effects of early mobilization therapy for non-emergency cardiac surgery patients in the intensive care unit (ICU).

The following databases will be used to search for relevant keywords: PubMed, Embase, CINAHL, PEDro, and the Cochrane Library from inception to September 2018 by 2 researchers independently. Randomized controlled trials (RCTs), will be included if patients are adults (≥18 years) admitted to any ICU for cardiac surgery due to cardiovascular disease and who are treated with experimental physiotherapy initiated in the ICU (pre, post, or perioperative). The Review Manager 5.3 will be used for meta-analysis and the evidence level will be assessed by using the method for Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Continuous outcomes will be presented as the weighted mean difference (WMD) or standardized mean difference (SMD) with 95% confidence interval (CI), while dichotomous data will be expressed as relative risk (RR) with 95% CI. If the included studies have existing heterogeneity (P < 0.1), a random-effects model will be used. Otherwise, we will calculate using a fixed effects model.

This review will evaluate the effects of early mobilization on length of ICU and hospital stay, physical function and adverse events in patients with cardiac surgery patients in the ICU.

This systematic review will comprehensively provide conclusive evidence of the therapeutic effect of early mobilization on cardiac surgery patients in the ICU.PROSPERO Research registration identifying number: CRD42019135338.

Physical therapy can prevent functional impairments and improve the quality of life of patients after hospital discharge. However, the effect of early mobilization on patients with a critical illness remains unclear. This study was performed to assess the evidence available regarding the effect of early mobilization on critically ill patients in the intensive care unit (ICU).

Electronic databases were searched from their inception to March 21, 2019. Randomized controlled trials (RCTs) comprising critically ill patients who received early mobilization were included. The methodological quality and risk of bias of each eligible trial were assessed using the Cochrane Collaboration tool. Data were extracted using a standard collection form each included study, and processed using the Mantel-Haenszel (M-H) or inverse-variance (I-V) test in the STATA v12.0 statistical software.

A total of 1,898 records were screened. Twenty-three RCTs comprising 2,308 critically ill patients were ultimately included. Early mobilization decreased the incidence of ICU-acquired weakness (ICU-AW) at hospital discharge (three studies, 190 patients, relative risk (RR): 0.60, 95% confidence interval (CI) [0.40, 0.90]; p = 0.013, I2 = 0.0%), increased the number of patients who were able to stand (one study, 50 patients, 90% vs. 62%, p = 0.02), increased the number of ventilator-free days (six studies, 745 patients, standardized mean difference (SMD): 0.17, 95% CI [0.02, 0.31]; p = 0.023, I2 = 35.5%) during hospitalization, increased the distance the patient was able to walk unassisted (one study, 104 patients, 33.4 (0-91.4) meters vs. 0 (0-30.4) meters, p = 0.004) at hospital discharge, and increased the discharged-to-home rate (seven studies, 793 patients, RR: 1.16, 95% CI [1.00, 1.34]; p = 0.046). The mortality (28-day, ICU and hospital) and adverse event rates were moderately increased by early mobilization, but the differences were statistically non-significant. However, due to the substantial heterogeneity among the included studies, and the low quality of the evidence, the results of this study should be interpreted with caution. Publication bias was not identified.

Early mobilization appears to decrease the incidence of ICU-AW, improve the functional capacity, and increase the number of ventilator-free days and the discharged-to-home rate for patients with a critical illness in the ICU setting.

Skeletal muscle mass with aging, during critical care, and following critical care is a determinant of quality of life and survival. In this review, we discuss the mechanisms that underpin skeletal muscle atrophy and recommendations to offset skeletal muscle atrophy with aging and during, as well as following, critical care.

Anabolic resistance is responsible, in part, for skeletal muscle atrophy with aging, muscle disuse, and during disease states. Anabolic resistance describes the reduced stimulation of muscle protein synthesis to a given dose of protein/amino acids and contributes to declines in skeletal muscle mass. Physical inactivity induces: anabolic resistance (that is likely exacerbated with aging), insulin resistance, systemic inflammation, decreased satellite cell content, and decreased capillary density. Critical illness results in rapid skeletal muscle atrophy that is a result of both anabolic resistance and enhanced skeletal muscle breakdown.

Insofar as atrophic loss of skeletal muscle mass is concerned, anabolic resistance is a principal determinant of age-induced losses and appears to be a contributor to critical illness-induced skeletal muscle atrophy. Older individuals should perform exercise using both heavy and light loads three times per week, ingest at least 1.2 g of protein/kg/day, evenly distribute their meals into protein boluses of 0.40 g/kg, and consume protein within 2 h of retiring for sleep. During critical care, early, frequent, and multimodal physical therapies in combination with early, enteral, hypocaloric energy (∼10-15 kcal/kg/day), and high-protein (>1.2 g/kg/day) provision is recommended.

Rehabilitation after critical illness requires a multidisciplinary effort. Nutrition support of critically ill patients aims to correct the imbalance between protein synthesis and protein degradation to maximize strengthening and muscle mass, whereas physical and occupational therapists focus on optimizing strength and mobility through functional activity to help intensive care (ICU) patients return to their precritical illness level of function and improve quality of life. Early mobility has become the new standard of care for ICU patients. Therapists utilize various devices and technologies to increase the feasibility of early mobility and enhance the rehabilitation process to ensure that patients reach their rehabilitation goals. Tools such as electrical stimulation, cycle ergometers, dynamic tilt tables, and resistive bands aid in strengthening. Therapists use safe patient-handling equipment and ambulation aids to address gait impairments. Adaptive toileting, dressing, bathing, and feeding tools facilitate greater independence with activities of daily living. Augmentative and alternative communication devices promote well-being and communication of basic needs. Splints prevent joint contracture and maintain functional range of motion. Overall, many rehabilitation devices are safe and feasible for use in an ICU setting and serve to maximize strength and functional independence. The purpose of this narrative review is to discuss the benefits and limitations of available rehabilitation devices in the context of critical illness rehabilitation goals.

[Purpose] To examine if length of stay was reduced following an early mobilisation programme in patients with community-acquired pneumonia, and secondary, if such a program influenced short-term rehospitalisation and mortality rates. [Participants and Methods] Ninety seven consecutive patients (51% men; over all mean ± SD age 71.9 ± 16.5 years) with community-acquired pneumonia were included in the intervention group, and compared with a historical control group of 97 patients, matching at case level. Early mobilisation was defined as more than 20 minutes out of bed within 24 hours of hospitalisation. [Results] Eighty out of 97 patients in the intervention group were mobilised within 24 hours and length of stay for all patients was reduced with an average of 1.5 (95%CI: -0.2; 3.2) days compared to the control group. There was no significant difference between the two groups according to 30-day rehospitalisation and mortality. [Conclusion] An early mobilisation program seem to reduce the length of stay for patients with community-acquired pneumonia, and without an increase in short-term mortality and re-hospitalisation rates.

Many intensive care unit (ICU) patients do not achieve target protein intakes particularly in the early days following admittance. This period of iatrogenic protein undernutrition contributes to a rapid loss of lean, in particular muscle, mass in the ICU. The loss of muscle in older (aged >60 years) patients in the ICU may be particularly rapid due to a perfect storm of increased catabolic factors, including systemic inflammation, disuse, protein malnutrition, and reduced anabolic stimuli. This loss of muscle mass has marked consequences. It is likely that the older patient is already experiencing muscle loss due to sarcopenia; however, the period of stay in the ICU represents a greatly accelerated period of muscle loss. Thus, on discharge, the older ICU patient is now on a steeper downward trajectory of muscle loss, more likely to have ICU-acquired muscle weakness, and at risk of becoming sarcopenic and/or frail. One practice that has been shown to have benefit during ICU stays is early ambulation and physical therapy (PT), and it is likely that both are potent stimuli to induce a sensitivity of protein anabolism. Thus, recommendations for the older ICU patient would be provision of at least 1.2-1.5 g protein/kg usual body weight/d, regular and early utilization of ambulation (if possible) and/or PT, and follow-up rehabilitation for the older discharged ICU patient that includes rehabilitation, physical activity, and higher habitual dietary protein to change the trajectory of ICU-mediated muscle mass loss and weakness.

Physical rehabilitation of lung transplant candidates and recipients plays an important in optimizing physical function prior to transplant and facilitating recovery of function post-transplant. As medical and surgical interventions in lung transplantation have evolved over time, there has been a demographic shift of individuals undergoing lung transplantation including older individuals, those with multiple co-morbidites, and candidates with respiratory failure requiring bridging to transplantation. These changes have an impact on the rehabilitation needs of lung transplant candidates and recipients. This review provides a practical approach to rehabilitation based on research and clinical practice at our transplant centre. It focuses on functional assessment and exercise prescription during an uncomplicated and complicated clinical course in the pre-transplant, early and late post-transplant periods. The target audience includes clinicians involved in pre- and post-transplant patient care and rehabilitation researchers.