Early Mobilization Protocol Research Articles

Impact of Early Mobilization Protocol on the Medical-Surgical Inpatient Population

The purpose of this review article was to examine the efficacy of an early mobilization protocol in hospitalized medical-surgical inpatient population. Prolonged immobilization can result in functional decline and heighten the risk for hospital-associated complications such as falls and pressure ulcers. Early mobilization, on the other hand, has been shown to prevent functional decline and hospital-associated complications. However, currently no evidence-based guidelines exist with regard to an early mobilization protocol for the medical-surgical inpatient population. Therefore, the purpose of this review was to provide a thorough analysis of current evidence pertaining to an early mobilization protocol for the medical-surgical inpatient population. A comprehensive search of the literature was conducted using Ovid, MEDLINE, and PubMed databases using the following search terms: early ambulation, postoperative care, and length of stay. We found a total of 9 empirical studies that met the inclusion criteria. Studies revealed that using the basic tenets of an early mobilization protocol was associated with improved outcomes for patients with deep vein thrombosis, reduced length of stay in patients with community-acquired pneumonia, and maintained or improved functional status from admission to discharge of hospitalized older adults and patients recovering from major surgery. Overall, our review found that early mobilization (especially early ambulation) of the medical-surgical inpatient population may improve patient outcomes. Our review indicated that the greatest impact of early mobilization is through standardized mobility protocols or programs. Clinical nurse specialists are experts in leading and sustaining standardized protocols or programs pertaining to a nurse-sensitive outcome such as mobility.

Developing a Mobility Protocol for Early Mobilization of Patients in a Surgical/Trauma ICU

As technology and medications have improved and increased, survival rates are also increasing in intensive care units (ICUs), so it is now important to focus on improving the patient outcomes and recovery. To do this, ICU patients need to be assessed and started on an early mobility program, if stable. While the early mobilization of the ICU patients is not without risk, the current literature has demonstrated that patients can be safely and feasibly mobilized, even while requiring mechanical ventilation. These patients are at a high risk for muscle deconditioning due to limited mobility from numerous monitoring equipment and multiple medical conditions. Frequently, a critically ill patient only receives movement from nurses; such as, being turned side to side, pulled up in bed, or transferred from bed to a stretcher for a test. The implementation of an early mobility protocol that can be used by critical care nurses is important for positive patient outcomes minimizing the functional decline due to an ICU stay. This paper describes a pilot study to evaluate an early mobilization protocol to test the safety and feasibility for mechanically ventilated patients in a surgical trauma ICU in conjunction with the current unit standards.

Early Mobilization in the Intensive Care Unit

As mortality from critical illness continues to decrease, focus has shifted to long-term outcomes of ICU survivors. Neuromuscular weakness is a common sequela of critical illness. This weakness prolongs duration of mechanical ventilation, increases ICU and hospital length of stay, increases mortality, and can persist for years after hospital discharge. The differential diagnosis of weakness in the ICU is long, and includes critical illness polyneuropathy (CIP) and critical illness myopathy (CIM). Immobilization and bed rest likely contribute to the development of CIP/CIM. Thus, early mobilization therapy has been suggested as an intervention to prevent or ameliorate ICU-acquired weakness. Early mobilization is safe, feasible, and associated with improved ICU outcomes. Emerging evidence suggests patients receiving early mobilization are more likely to be discharged home, making early mobilization therapy a potential mechanism to contain health care costs. Successful implementation of an early mobilization protocol requires changes in ICU culture and can be achieved using a structured quality improvement framework.

Early mobilization out of bed after ischaemic stroke reduces severe complications but not cerebral blood flow: a randomized controlled pilot trial

Objective: To evaluate whether early mobilization after acute ischaemic stroke is better than delayed mobilization with regard to medical complications and if it is safe in relation to neurological function and cerebral blood flow. Design: Randomized controlled pilot trial of early versus delayed mobilization out of bed with incidence of severe complications as the primary outcome. Setting: Acute stroke unit in the neurology department of a University Hospital. Participants: Fifty patients after ischaemic stroke with a National Institutes of Health Stroke Scale (NIHSS) score >6 were recruited. Intervention: All patients were treated with physiotherapy immediately after their admission. In the early protocol patients were mobilized out of bed after 52 hours, in the delayed protocol after seven days. Results: Eight out of 50 randomized patients were excluded from the per-protocol analysis because of early transfer to other hospitals. There were 2 (8%) severe complications in the 25 early mobilization patients and 8 (47%) in the 17 delayed mobilization patients (P < 0.006). There were no differences in the total number of complications or in clinical outcome. In the 26 patients (62%) who underwent serial transcranial Doppler ultrasonography, no blood flow differences were found. Conclusion: We found an apparent reduction in severe complications and no increase in total complications with an early mobilization protocol after acute ischaemic stroke. No influence on neurological three-month outcomes or on cerebral blood flow was seen. These results justify larger trials comparing mobilization protocols with possibly even faster mobilization out of bed than explored here.

An Early Mobilization Protocol Successfully Delivers More and Earlier Therapy to Acute Stroke Patients

Background. The optimal physical therapy dose in acute stroke care is unknown. The authors hypothesized that physical therapy would be significantly different between treatment arms in a trial of very early and frequent mobilization (VEM) and that immobility-related adverse events would be associated with therapy dose. Methods. This study was a single-blind, multicenter, randomized control trial. Patients admitted to a stroke unit <24 hours of stroke randomized to standard care (SC) or intervention, SC plus additional early out-of-bed therapy (VEM). Timing, amount, and type of therapy recorded throughout the trial. Adverse events were recorded to 3 months. Results. A total of 71 patients (SC n = 33, VEM n = 38) received 788 therapy sessions in the first 2 weeks of stroke. Schedule (hours to first mobilization, dose per day, frequency and session duration) and nature (percentage out-of-bed activity) of therapy differed significantly between groups (P ≤ .001 for all components). Mobilization was earlier, happened on average 3 times per day in those receiving VEM, with the proportion of out-of-bed activity double in VEM session (median SC 42.5%, VEM 85.5%). SC consisted of 17 minutes of occupational and physiotherapy per day and was the same between groups. Number of immobility-related adverse events 3 months poststroke was not associated with therapy dose or frequency. Conclusions. The authors detailed usual care and intervention therapy provided to patients from admission to 14 days after stroke. The therapy schedule was markedly different in the intervention arm, but whether this schedule reduces complications or improves outcome is unknown.

Acute Achilles Tendon Rupture

Background There is no consensus regarding the optimal treatment for patients with acute Achilles tendon rupture. Few randomized controlled studies have compared outcomes after surgical or nonsurgical treatment with both groups receiving early mobilization. Purpose This study was undertaken to compare outcomes of patients with acute Achilles tendon rupture treated with or without surgery using early mobilization and identical rehabilitation protocols. Study Design Randomized, controlled trial; Level of evidence, 1. Methods Ninety-seven patients (79 men, 18 women; mean age, 41 years) with acute Achilles tendon rupture were treated and followed for 1 year. The primary end point was rerupturing. Patients were evaluated using the Achilles tendon Total Rupture Score (ATRS), functional tests, and clinical examination at 6 and 12 months after injury. Results There were 6 (12%) reruptures in the nonsurgical group and 2 (4%) in the surgical group (P = .377). The mean 6- and 12-month ATRS were 72 and 88 points in the surgical group and 71 and 86 points in the nonsurgical group, respectively. Improvements in ATRS between 6 and 12 months were significant for both groups, with no significant between-group differences. At the 6-month evaluation, the surgical group had better results compared with the nonsurgically treated group in some of the muscle function tests; however, at the 12-month evaluation there were no differences between the 2 groups except for the heel-rise work test in favor of the surgical group. At the 12-month follow-up, the level of function of the injured leg remained significantly lower than that of the uninjured leg in both groups. Conclusion The results of this study did not demonstrate any statistically significant difference between surgical and nonsurgical treatment. Furthermore, the study suggests that early mobilization is beneficial for patients with acute Achilles tendon rupture whether they are treated surgically or nonsurgically. The preferred treatment strategy for patients with acute Achilles tendon rupture remains a subject of debate. Although the study met the sample size dictated by the authors’ a priori power calculation, the difference in the rerupture rate might be considered clinically important by some.

Outcome of early active mobilization after flexor tendons repair in zones II-V in hand.

Background:The functional outcome of a flexor tendon injury after repair depends on multiple factors. The postoperative management of tendon injuries has paved a sea through many mobilization protocols. The improved understanding of splinting techniques has promoted the understanding and implication of these mobilization protocols. We conducted a study to observe and record the results of early active mobilization of repaired flexor tendons in zones II–V.Materials and Methods:25 cases with 75 digits involving 129 flexor tendons including 8 flexor pollicis longus (FPL) tendons in zones II–V of thumb were subjected to the early active mobilization protocol. Eighteen (72%) patients were below 30 years of age. Twenty-four cases (96%) sustained injury by sharp instrument either accidentally or by assault. Ring and little finger were involved in 50% instances. In all digits, either a primary repair (n=26) or a delayed primary repair (n=49) was done. The repair was done with the modified Kessler core suture technique with locking epitendinous sutures with a knot inside the repair site, using polypropylene 3-0/4-0 sutures. An end-to-end repair of the cut nerves was done under loupe magnification using a 6-0/8-0 polyamide suture. The rehabilitation program adopted was a modification of Kleinert’s regimen, and Silfverskiold regimen. The final assessment was done at 14 weeks post repair using the Louisville system of Lister et al.Results:Eighteen of excellent results were attributed to ring and little fingers where there was a flexion lag of < 1 cm and an extension lag of < 15°. FPL showed 75% (n=6) excellent flexion. 63% (n=47) digits showed excellent results whereas good results were seen in 19% (n=14) digits. Nine percent (n=7) digits showed fair and the same number showed poor results. The cases where the median (n=4) or ulnar nerve (n=6) or both (n=3) were involved led to some deformity (clawing/ape thumb) at 6 months postoperatively. The cases with digital or common digital nerve involvement (n=7 with 17 digits) showed five excellent, two good, four fair, and six poor results. Complications included tendon ruptures in 2 (3%) cases (one thumb and one ring finger) and contracture in 2 (3%) cases whereas superficial infection and flap necrosis was seen in 1 case each.Conclusion:The early active mobilization of cut flexor tendons in zones II–V using the modified mobilization protocol has given good results, with minimal complications.

The Four-Strand Staggered Suture for Flexor Tendon Repair: In Vitro Biomechanical Study

To assess in vitro biomechanical properties of a 4-strand flexor tendon suture compared to 3 established suture techniques. This technique, which is made of 2 alternating and staggered sutures, one external to the tendon and the other internal, must be sufficiently resistant to withstand loads applied by modern, early active mobilization protocols. Forty flexor hallucis longus tendons were harvested from fresh cadavers, cut, and repaired using 4 different suture techniques (Strickland, Wolfe, modified Savage, and a new technique called 4-strand staggered). All repaired tendons were submitted to static loading trials to measure gap formation (2 mm) in relation to tensile force and breaking force of all 4 sutures. Twenty additional tendons were repaired with the new suture technique and submitted to dynamic trials under cyclic loading. The 4-strand staggered suture technique proved to be statistically superior to Strickland and modified Savage techniques following the static loading trials for gap formation and breaking force. This technique is statistically superior to the Wolfe cruciate suture for breaking force and superior but not statistically significant for gap formation. The dynamic loading trials have shown that the 4-strand staggered suture can tolerate in vitro loads similar to those exerted by modern, early active mobilization protocols. The suture technique created by the authors proved to hold superior biomechanical properties than the other techniques tested in this study and might be suitable for early active mobilization protocols.

Efficacy and safety of postoperative early mobilization for chronic subdural hematoma in elderly patients

The incidences of chronic subdural hematoma (CSDH) will probably increase with the aging of the population; thus, postoperative care of elderly CSDH patients may play a more important role in surgical management. The aim of this study was to evaluate the efficacy of and adverse effects after postoperative early mobilization (EM) for elderly CSDH patients. This is a single-institution historical control study. One hundred eighty-two patients with CSDH aged 65 years and older underwent one burr-hole surgery between 2001 and 2008. This institution has prospectively conducted an EM protocol after surgery since 2005. The emphasis of the EM was helping patients not only to an upright position but also to walk beginning the day of operation. The incidences of postoperative complications and recurrence of CSDH were compared between the EM group (n = 91; 76.5 +/- 6.5 years old) and a delayed mobilization (DM) group (n = 91; 77.9 +/- 7.5 years old). Postoperative complications, such as pneumonia and urinary tract infection, was observed in 24 (26.4%) in the DM group and 11 (12.1%) in the EM group (p < 0.05). The rate of recurrence did not differ between the two groups (6.6% and 8.8%, respectively; p = 0.58). The results suggest that EM after one burr-hole surgery prevents postoperative complications without increasing the risk of recurrence in CSDH patients > or =65 years of age.

HS12P THE DONA TECHNIQUE FOR FDP AND EDC TENDON FIXATION TO THE DISTAL PHALANX

Purpose: Common methods of repair of zone 1 flexor digitorum profundus (FDP) or extensor tendon avulsion or laceration are the modified Bunnell pullout and suture anchor techniques. While these techniques have extensive use clinically, results show a 75% fair to poor outcome. We present a simple technique for repairing these injuries and discuss its rationale.Methodology: A retrospective analysis was undertaken on a consecutive cohort of 5 patients that were treated by the relatively simple method of (1) securing the FDP tendon stump with a 4‐0 Fibreloop suture in a standard Kessler suture configuration (2) creation of transosseous tunnels and (3) passing the sutures through the base of the distal phalanx and then tying them volar to the FDP tendon stump, which effectively results in a 4 strand tendon and 4 strand transosseous suture repair.Results: Six month follow up of MCP, PIP, and DIP joint flexion was 99%, 95%, and 86% of that of the uninjured side, respectively, with no complications. All patients were able to return to their pre‐injury level of functioning and employment, with no further operations required. This technique has also been employed when repairing open mallet finger injuries. Additionally, similar principles are used when repairing volar plate avulsion injuries.Conclusion: The technique avoids the morbidity associated with both the pullout button and suture anchor techniques, while providing an inexpensive, and highly reproducible, four‐strand biomechanically sound repair that allows an early active mobilization protocol to maximize return of function.

Early mobilisation after conventional knee replacement may reduce the risk of postoperative venous thromboembolism

We carried out an audit on the result of achieving early walking in total knee replacement after instituting a new rehabilitation protocol, and assessed its influence on the development of deep-vein thrombosis as determined by Doppler ultrasound scanning on the fifth post-operative day. Early mobilisation was defined as beginning to walk less than 24 hours after knee replacement. Between April 1997 and July 2002, 98 patients underwent a total of 125 total knee replacements. They began walking on the second post-operative day unless there was a medical contraindication. They formed a retrospective control group. A protocol which allowed patients to start walking at less than 24 hours after surgery was instituted in August 2002. Between August 2002 and November 2004, 97 patients underwent a total of 122 total knee replacements. They formed the early mobilisation group, in which data were prospectively gathered. The two groups were of similar age, gender and had similar medical comorbidities. The surgical technique and tourniquet times were similar and the same instrumentation was used in nearly all cases. All the patients received low-molecular-weight heparin thromboprophylaxis and wore compression stockings post-operatively. In the early mobilisation group 90 patients (92.8%) began walking successfully within 24 hours of their operation. The incidence of deep-vein thrombosis fell from 27.6% in the control group to 1.0% in the early mobilisation group (chi-squared test, p < 0.001). There was a difference in the incidence of risk factors for deep-vein thrombosis between the two groups. However, multiple logistic regression analysis showed that the institution of an early mobilisation protocol resulted in a 30-fold reduction in the risk of post-operative deep-vein thrombosis when we adjusted for other risk factors.

Postoperative Management Protocol for Incidental Dural Tears During Degenerative Lumbar Spine Surgery

Retrospective review. To review the experience of a single institution with degenerative lumbar surgery and to identify cases of incidental dural tears (DTs); and to report on the efficacy of our postoperative management protocol for DT, which relies on early mobilization. DTs are a common complication of degenerative lumbar spine surgery. However, the management strategies for this complication vary from one surgeon to another. A total of 3,183 degenerative lumbar spine cases (decompression and/or fusion) were reviewed. Cases complicated by an incidental DT were identified. Patients who required a return to the operating room for a second procedure were identified and the operative findings were reviewed. The incidence of DT during primary lumbar surgeries was 7.6% (153 of 2,024 cases), which compares to an incidence of 15.9% for revision cases (185 of 1,159 cases). If recognized during the index procedure, all DTs were repaired using a 4-0 silk suture. Six patients (4 primary, 2 revisions) who did not improve despite our postoperative management protocol were taken to the operating room for irrigation and debridement, repair of the defect, and placement of a subfascial drain to closed suction. All 6 patients went on to do well and did not have any further complications. DTs are common during degenerative lumbar spine surgery. Revision surgery is twice as likely as primary surgery to result in this complication. Our postoperative early mobilization protocol appears to be an effective and safe management strategy for treating this complication (98.2% success rate). Very few patients (6 of 338, or 1.8%) needed a reoperation.

Some technical tips to improve two stages flexor tendon grafting

Two-stage reconstruction of the profundus tendon with a tendon graft is a technically demanding procedure. Results from a series of 16 cases demonstrate the importance of a good soft tissue bed, as well as pulley reconstruction. The accumulation of technical experience, together with early mobilisation protocols, has helped to improve the functional results. The first operative procedure employs a silicone rod, which has an oval cross section and a conical shape, which adapts to the volumetric variations of the digital canal. Pulley reconstruction should be generous, including A1, A2, A3, and A4. Attachment of the profundus tendon to palmaris longus at the first stage guarantees a sound repair, which permits early tendon mobilisation after the second stage. Attachment of the tendon graft to the distal phalanx is carried out using an absorbable mini-anchor, and is reinforced with a fingernail suture. A series of 12 Stage 1 and Stage 2 patients had an average total active motion (TAM) of 223° with a residual interphalangeal joint flexion of −15°. In Stage 3 patients (four cases) one early rupture and two tenolyses resulted in TAM of 160° and 165°. For Stage 1 and 2 patients, the Strickland active rehabilitation protocol gives the best functional results.

Achilles Tendon Rupture: Effect of Early Mobilization in Rehabilitation After Surgical Repair

Surgical and nonsurgical treatments of Achilles tendon ruptures are available. Nonsurgical treatment using immobilization does not have the varying degrees of infection as seen with surgical procedures, but it frequently is linked to muscle atrophy, weakness, and higher rates of rerupture than surgical treatment. This study reports the results of 64 patients with Achilles tendon ruptures treated surgically and with early mobilization. Surgery of the ruptured tendon involved dividing the proximal stump into two separate strands and the distal stump into a single strand. The repair was advanced to a V-Y formation, and nonabsorbable sutures were used for repair. After wound closure, an early mobilization rehabilitation program was initiated, which consisted of wearing a moveable ankle brace for 4 to 6 weeks in 0 to 15 degrees of dorsiflexion and 10 weeks of regular exercises. All 64 patients resumed normal activities in an average of 3.3 months regardless of whether the rupture was acute or chronic. Tendons healed with no reruptures. There were 13 complications, all wound infections, which healed when treated with antibiotics. The infection rate dropped markedly when wounds were inspected and dressings changed 1 week postoperatively, instead of at 2 weeks. Surgery combined with early mobilization reduces range of motion loss, increases blood supply, and reduces the degree of muscle atrophy that typically occurs after Achilles tendon rupture, thereby decreasing the time to resumption of normal activities. Applying tension to the tendon also improved strength of the calf muscles and improved ankle movement. The main concern with early mobilization is rerupture, but this was lessened by patients carefully following the weightbearing and early mobilization protocols. The results of this study strengthen the argument to employ early mobilization rehabilitation after surgical repair.

Early mobilization after pacemaker implantation

There are no international guidelines indicating how long a patient should stay strictly in bed after pacemaker implantation. In the present study, we tested a new protocol concerning the mobilization of patients 3 h after receiving a single or a dual-chamber pacemaker. Consecutive patients who underwent single or dual-chamber pacemaker implantation were randomized to a 3 or 24 h immobilization protocol. Only bipolar passive fixation leads were computed. After the implant, an elastic bandage was put on the homolateral shoulder of all patients for 24 h. A complete clinical and electronic follow-up was performed before discharge and repeated 2 months later. End-points considered were the displacement of the lead, high pacing thresholds (> 3.5 V/0.4 ms at the discharge or > 2.5 V/0.4 ms at the 2-month follow-up), sensing defects not corrigible by programming and clinical complications of the pocket One hundred and thirty-four patients were included in the study: 57 in group A (mobilization after 3 h) and 77 in group B (24 h). In group A, one haematoma and two displacements occurred in three patients. In group B, we registered one haematoma, one subclavian vein thrombosis, three displacements and three high stimulation thresholds. No statistical differences were observed between the end-points of group A versus B. The present study shows that an early mobilization protocol is feasible because no statistical differences resulted from the two groups of study as regards clinical outcome, complications and electronic measurements of the implanted devices, which have been followed up for 2 months.

Inactive and alone: physical activity within the first 14 days of acute stroke unit care.

One way that stroke units may improve outcome is by reducing complications of immobility through early mobilization; however, this intervention needs testing. The purpose of this study was to determine the physical activity patterns of stroke patients managed within acute stroke units as a first step in developing an early mobilization protocol. We recruited 64 patients within 14 days after stroke from 5 metropolitan stroke units and observed them for 2 consecutive days at 10-minute intervals between the hours of 8 am and 5 pm. At each observation, we ascertained physical activity, location, and other person(s) present. Therapists recorded therapy details. The 58 patients who completed the study had a mean age of 71.3 years. Stroke severity ranged from mild (National Institutes of Health Stroke Scale score, 1) to severe (score, 27), and mean time after stroke at observation was 5.6 days (range, 0 to 13 days). Only 9 patients were restricted to bed. During the therapeutic day, patients spent >50% resting in bed, 28% sitting out of bed, and only 13% engaged in activities with the potential to prevent complications and improve recovery of mobility. Patients were alone >60% of the time. This is the first multicenter study of physical activity early after stroke. We believe the next step is to conduct a randomized controlled trial to evaluate the effect of increased levels of physical activity early after stroke compared with current standards of care.

EFFECT OF A NEW REPAIR TECHNIQUE ON BIOMECHANICAL PROPERTIES OF CANINE FLEXOR TENDONS — IN VITRO STUDY

A new repair technique that was easy to perform yet offered adequate strength was developed. The purpose of this study was to evaluate the mechanical properties of flexor tendon repairs undertaken with this technique. Thirty-two canine cadaver flexor digitorum profundus tendons in Zone 2 were lacerated and repaired with the technique, which consisted of a four-strand core suture using the double-modified Kessler method in combination with a cross-stitch circumferential suture. A 5–0 coated braided polyester suture and a 5–0 ultra-high molecular weight polyethylene suture were used as the core suture, and a 6–0 polypropylene monofilament was used as the circumferential suture. Tendons repaired with the 5–0 braided polyester suture had gap strengths (2.07 ± 0.46 kgf) and breaking strengths (6.03 ± 0.55 kgf), which were sufficient to withstand an early active mobilization protocol. There were no significant differences regarding mechanical properties between the two suture materials. This combined suture technique has the potential to be utilized in in vivo cases.

Review and Comparison of Current Trends in the Postoperative Management of Tendon Repair

The precision of the Evans/Burkhalter protocol and the work by Silverman and associates exemplify one of the most valuable of all current trends in rehabilitation of the healing tendon. Knowledge of tendon excursion at each level and throughout the range of motion in each joint gives us safe parameters for tendon mobilization. Hand rehabilitation is becoming more of a science while remaining an art. Research into tendon healing, nutrition, anatomy, biomechanics, and physiology gives us a solid basis for our treatment techniques. We now need to replicate studies already performed and quantify more precisely the data we have. Many questions remain unanswered. There is a wide variety in the position of splinting for flexor tendon mobilization under current protocols: What joint positions are optimal and why? The number and frequency of repetitions in early mobilization protocols varies greatly: What number and frequency is more appropriate for which patients? How much tendon excursion will control adhesions, promote healing, and avoid gap formation or elongation of the repair? How much force should we apply passively to maintain or increase joint motion? How soon should we start active motion, and how can we control the strength of those early muscle contractions? Do "place-hold" exercises truly place less tension on the repair site? How soon should we begin resisted exercise, and how much resistance are we applying with each type of exercise? Should blocking exercises be considered resistive? How should tendon management protocols be adapted in the presence of associated injuries? Lack of space has prevented discussion here of recent and needed research in a number of areas, such as the effectiveness and appropriate precautions for the use of ultrasound, iontophoresis, and neuromuscular electrical stimulation in tendon management. The evidence is growing, but we have a long way to go. To improve our clinical results, the trend toward precision must continue and grow.