J Pediatr Intensive Care 2018; 07(01): 014-026
DOI: 10.1055/s-0037-1601424
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Practice Recommendations for Early Mobilization in Critically Ill Children

Karen Choong
1   Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
2   Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
Filomena Canci
3   Pediatric Intensive Care Unit, McMaster Children's Hospital, Hamilton, Ontario, Canada
Heather Clark
3   Pediatric Intensive Care Unit, McMaster Children's Hospital, Hamilton, Ontario, Canada
Ramona O. Hopkins
4   Psychology Department and Neuroscience Center, Brigham Young University, Provo, Utah, United States
5   Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah, United States
6   Center for Humanizing Critical Care, Intermountain Healthcare, Murray, Utah, United States
Sapna R. Kudchadkar
7   Department of Anesthesiology and Critical Care Medicine and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
Jamil Lati
8   Division of Rehabilitation, Department of Physical Therapy, University of Toronto, The Hospital for Sick Children, Toronto, Canada
Brenda Morrow
9   Department of Pediatrics and Child Health, University of Cape Town, South Africa
Charmaine Neu
3   Pediatric Intensive Care Unit, McMaster Children's Hospital, Hamilton, Ontario, Canada
Beth Wieczorek
7   Department of Anesthesiology and Critical Care Medicine and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
Carleen Zebuhr
10   Section of Critical Care, Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado, United States
› Author Affiliations
Further Information

Publication History

08 January 2017

23 February 2017

Publication Date:
10 April 2017 (online)


Prolonged immobility is associated with significant short- and long-term morbidities in critically ill adults and children. The majority of critically ill children remain immobilized while in the pediatric intensive care unit (PICU) due to limited awareness of associated morbidities, lack of comfort and knowledge on how to mobilize critically ill children, and the lack of pediatric-specific practice guidelines. The objective of this article was to develop consensus practice recommendations for safe, early mobilization (EM) in critically ill children. A group of 10 multidisciplinary experts with clinical and methodological expertise in physical rehabilitation, EM, and pediatric critical care collaborated to develop these recommendations. First, a systematic review was conducted to evaluate existing evidence on EM in children. Using an iterative process, the working document was circulated electronically to panel members until the group reached consensus. The group agreed that the overall goals of mobilization are to reduce PICU morbidities and optimize recovery. EM should therefore not be instituted in isolation but as part of a rehabilitation care bundle. Mobilization should not be delayed, but its appropriateness and safety should be assessed early. Increasing levels of physical activity should be individualized for each patient with the goal of achieving the highest level of functional mobility that is developmentally appropriate, for increasing durations, daily. We developed a system-based set of clinical safety criteria and a checklist to ensure the safety of mobilization in critically ill children. Although there is a paucity of pediatric evidence on the efficacy of EM, there is ample evidence that prolonged bed rest is harmful and should be avoided. These EM practice recommendations were developed to educate clinicians, encourage safe practices, reduce PICU-acquired morbidities, until future pediatric research provides evidence on effective rehabilitation interventions and how best to implement these in critically ill children.

Authors' Contributions

K.C. conceived of the study and drafted and revised the article. K.C., R.S., and S.A. performed the systematic review. K.C., F.C., H.C., and C.N. drafted the tables and figures. All authors participated in the development of each of the practice recommendations. All authors contributed to the interpretation of results and reviewed and edited the article. All authors approved the final submitted version for publication.

  • References

  • 1 Pollack MM, Holubkov R, Funai T. , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. Pediatric intensive care outcomes: development of new morbidities during pediatric critical care. Pediatr Crit Care Med 2014; 15 (09) 821-827
  • 2 Needham DM, Davidson J, Cohen H. , et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference. Crit Care Med 2012; 40 (02) 502-509
  • 3 Iwashyna TJ, Ely EW, Smith DM, Langa KM. Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 2010; 304 (16) 1787-1794
  • 4 Knoester H, Bronner MB, Bos AP. Surviving pediatric intensive care: physical outcome after 3 months. Intensive Care Med 2008; 34 (06) 1076-1082
  • 5 Desai SV, Law TJ, Needham DM. Long-term complications of critical care. Crit Care Med 2011; 39 (02) 371-379
  • 6 Biagas KV, Hough RF. Post-intensive care syndrome: A look at PICU outcomes. Pediatr Crit Care Med 2016; 17 (11) 1101 . Doi: 10.1097/PCC.0000000000000975
  • 7 Kayambu G, Boots R, Paratz J. Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Crit Care Med 2013; 41 (06) 1543-1554
  • 8 Adler J, Malone D. Early mobilization in the intensive care unit: a systematic review. Cardiopulm Phys Ther J 2012; 23 (01) 5-13
  • 9 Stiller K. Physiotherapy in intensive care: an updated systematic review. Chest 2013; 144 (03) 825-847
  • 10 Cuthbertson BH, Rattray J, Campbell MK. , et al; PRaCTICaL study group. The PRaCTICaL study of nurse led, intensive care follow-up programmes for improving long term outcomes from critical illness: a pragmatic randomised controlled trial. BMJ 2009; 339: b3723 . Doi: 10.1136/bmj.b3723
  • 11 Bourgeois FT, Murthy S, Pinto C, Olson KL, Ioannidis JP, Mandl KD. Pediatric versus adult drug trials for conditions with high pediatric disease burden. Pediatrics 2012; 130 (02) 285-292
  • 12 Choong K, Foster G, Fraser DD. , et al; Canadian Critical Care Trials Group. Acute rehabilitation practices in critically ill children: a multicenter study. Pediatr Crit Care Med 2014; 15 (06) e270-e279
  • 13 Cremer R, Leclerc F, Lacroix J, Ploin D. ; GFRUP/RMEF Chronic Diseases in PICU Study Group. Children with chronic conditions in pediatric intensive care units located in predominantly French-speaking regions: Prevalence and implications on rehabilitation care need and utilization. Crit Care Med 2009; 37 (04) 1456-1462
  • 14 Bybee J, Sorce L, Ciolino J, Bone M. Mobility practices in the PICU. Crit Care Med 2015; 43 (12) (Suppl. 01) 213-214
  • 15 Choong K, Koo KK, Clark H. , et al. Early mobilization in critically ill children: a survey of Canadian practice. Crit Care Med 2013; 41 (07) 1745-1753
  • 16 Calvo-Ayala E, Khan BA, Farber MO, Ely EW, Boustani MA. Interventions to improve the physical function of ICU survivors: a systematic review. Chest 2013; 144 (05) 1469-1480
  • 17 Shaklai S, Peretz R, Spasser R, Simantov M, Groswasser Z. Long-term functional outcome after moderate-to-severe paediatric traumatic brain injury. Brain Inj 2014; 28 (07) 915-921
  • 18 Creighton DE, Robertson CM, Sauve RS. , et al; Western Canadian Complex Pediatric Therapies Follow-up Group. Neurocognitive, functional, and health outcomes at 5 years of age for children after complex cardiac surgery at 6 weeks of age or younger. Pediatrics 2007; 120 (03) e478-e486
  • 19 Cameron EC, Maehle V, Reid J. The effects of an early physical therapy intervention for very preterm, very low birth weight infants: a randomized controlled clinical trial. Pediatr Phys Ther 2005; 17 (02) 107-119
  • 20 Graham RJ, Mancher M, Miller Wolman D, Greenfield S, Steinberg E. , eds. Clinical Practice Guidelines We Can Trust. Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. Washington, DC: The National Academies Press; 2011
  • 21 Choong K, Chacon M, Walker R. , et al. In- bed mobilization in critically ill children: a safety and feasibility trial. J Pediatr Intensive Care 2015; 4 (02) 225-234
  • 22 Hollander SA, Hollander AJ, Rizzuto S, Reinhartz O, Maeda K, Rosenthal DN. An inpatient rehabilitation program utilizing standardized care pathways after paracorporeal ventricular assist device placement in children. J Heart Lung Transplant 2014; 33 (06) 587-592
  • 23 Zebuhr C, Sinha A, Skillman H, Buckvold S. Active rehabilitation in a pediatric extracorporeal membrane oxygenation patient. PM R 2014; 6 (05) 456-460
  • 24 Hodgson CL, Stiller K, Needham DM. , et al. Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Crit Care 2014; 18 (06) 658 . Doi: 10.1186/s13054-014-0658-y
  • 25 Perme C, Chandrashekar R. Early mobility and walking program for patients in intensive care units: creating a standard of care. Am J Crit Care 2009; 18 (03) 212-221
  • 26 Berry A, Beattie K, Bennett J. , et al. Physical Activity and Movement: A Guideline for Critically Ill Adults. New South Wales, Australia: Agency for Clinical Innovation NSW Government; 2014
  • 27 Gosselink R, Bott J, Johnson M. , et al. Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med 2008; 34 (07) 1188-1199
  • 28 Howick J, Chalmers I, Glasziou P. , et al; Oxford Centre for Evidence-Based Medicine. Explanation of the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence (Background Document). Available at: http://www.cebm.net/index.aspx?o=5653
  • 29 Morandi A, Brummel NE, Ely EW. Sedation, delirium and mechanical ventilation: the ‘ABCDE’ approach. Curr Opin Crit Care 2011; 17 (01) 43-49
  • 30 Balas MC, Vasilevskis EE, Olsen KM. , et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med 2014; 42 (05) 1024-1036
  • 31 Curley MA, Meyer E. Caring practices: the impact of the critical care experience on the family. In: Curley MA, Moloney-Harmon P. , eds. Critical Care Nursing of Infants and Children Section 1: Holistic Pediatric Critical Care Nursing. 2nd ed. Philadelphia, PA: WB Saunders Company; 2001: 47-68
  • 32 Camden C, Shikako-Thomas K, Nguyen T. , et al. Engaging stakeholders in rehabilitation research: a scoping review of strategies used in partnerships and evaluation of impacts. Disabil Rehabil 2015; 37 (15) 1390-1400
  • 33 Skillman HE, Zebuhr CA. Optimal nutrition for acute rehabilitation in the PICU. J Pediatr Intensive Care 2015; 4 (02) 194-203
  • 34 Verghese A. Culture shock–patient as icon, icon as patient. N Engl J Med 2008; 359 (26) 2748-2751
  • 35 Fontaine DK, Briggs LP, Pope-Smith B. Designing humanistic critical care environments. Crit Care Nurs Q 2001; 24 (03) 21-34
  • 36 Abdulsatar F, Walker RG, Timmons BW, Choong K. “Wii-Hab” in critically ill children: a pilot trial. J Pediatr Rehabil Med 2013; 6 (04) 193-204
  • 37 Choong K, Awladthani S, Khawaji A. , et al; Canadian Critical Care Trials Group. Early exercise in critically ill youth and children, a preliminary evaluation (the “wEECYCLE” pilot randomized trial). Clinicaltrialsgov identifier: NCT02358577. Available at: https://clinicaltrials.gov/ct2/show/NCT02358577?term=wEECYCLE&rank=1
  • 38 Wieczorek B, Ascenzi J, Kim Y. , et al. PICU Up!: Impact of a quality improvement program to promote early mobilization in critically ill children. Ped Crit Care Med 2016; 17 (12) e559-e566
  • 39 Tsuboi N, Nozaki H, Ishida Y. , et al. Early mobilization after pediatric liver transplantation. J Pediatr Intensive Care 2016; 6 (01) DOI: 10.1055/s-0036-1593387.
  • 40 Choong K, Tran N, Clark H, Cupido C, Corsi D. Acute rehabilitation in critically ill children. J Pediatr Intensive Care 2012; 1: 183-192
  • 41 Phillips AA, Cote AT, Warburton DE. A systematic review of exercise as a therapeutic intervention to improve arterial function in persons living with spinal cord injury. Spinal Cord 2011; 49 (06) 702-714
  • 42 Puthucheary ZA, Rawal J, McPhail M. , et al. Acute skeletal muscle wasting in critical illness. JAMA 2013; 310 (15) 1591-1600
  • 43 Bernhardt J, Langhorne P, Lindley RI. , et al; AVERT Trial Collaboration group. Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. Lancet 2015; 386 (9988): 46-55
  • 44 Burtin C, Clerckx B, Robbeets C. , et al. Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med 2009; 37 (09) 2499-2505
  • 45 Schweickert WD, Pohlman MC, Pohlman AS. , et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373 (9678): 1874-1882
  • 46 Denehy L, Skinner EH, Edbrooke L. , et al. Exercise rehabilitation for patients with critical illness: a randomized controlled trial with 12 months of follow-up. Crit Care 2013; 17 (04) R156 . Doi: 10.1186/cc12835
  • 47 Morris PE, Berry MJ, Files DC. , et al. Standardized rehabilitation and hospital length of stay among patients with acute respiratory failure: a randomized clinical trial. JAMA 2016; 315 (24) 2694-2702
  • 48 Moss M, Nordon-Craft A, Malone D. , et al. A randomized trial of an intensive physical therapy program for patients with acute respiratory failure. Am J Respir Crit Care Med 2016; 193 (10) 1101-1110
  • 49 Hodgson CL, Bailey M, Bellomo R. , et al; Trial of Early Activity and Mobilization Study Investigators. A binational multicenter pilot feasibility randomized controlled trial of early goal-directed mobilization in the ICU. Crit Care Med 2016; 44 (06) 1145-1152
  • 50 Brummel NE, Girard TD, Ely EW. , et al. Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the Activity and Cognitive Therapy in ICU (ACT-ICU) trial. Intensive Care Med 2014; 40 (03) 370-379
  • 51 Kho ME. CYCLE pilot randomized trial. ClinicalTrialsgov identifier: NCT02377830. Available at: https://clinicaltrials.gov/ct2/show/NCT02377830
  • 52 Remonidini R, Valerio N, Barcellos P, do Prado C, Santos E. Early mobilization in Children under invasive and noninvasive positive pressure ventilation: Description and preliminary results of a new protocol. Abstract presented at: 2012 International Conference of the American Thoracic Society. May 18–23, 2012 San Francisco: , CA. Abstract A1832
  • 53 Fink E. RCT: Early rehabilitation protocol vs. usual care in pediatric ICU for children with acute brain injury. Clinicaltrialsgov identifier: NCT02209935. Available at: https://clinicaltrials.gov/ct2/show/NCT02209935
  • 54 Choong K, Al-Harbi S, Alothani S. , et al. Early exercise in critically ill youth and children, a preliminary evaluation (the wEECYCLE pilot trial). ClinicalTrialsgov identifier: NCT00896220
  • 55 Kress JP, Hall JB. ICU-acquired weakness and recovery from critical illness. N Engl J Med 2014; 370 (17) 1626-1635
  • 56 Lee CM, Fan E. ICU-acquired weakness: what is preventing its rehabilitation in critically ill patients?. BMC Med 2012; 10 (01) 115 . Doi: 10.1186/1741-7015-10-115
  • 57 Bailey P, Thomsen GE, Spuhler VJ. , et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med 2007; 35 (01) 139-145
  • 58 Jacobs BR, Salman BA, Cotton RT, Lyons K, Brilli RJ. Postoperative management of children after single-stage laryngotracheal reconstruction. Crit Care Med 2001; 29 (01) 164-168
  • 59 Turner DA, Cheifetz IM, Rehder KJ. , et al. Active rehabilitation and physical therapy during extracorporeal membrane oxygenation while awaiting lung transplantation: a practical approach. Crit Care Med 2011; 39 (12) 2593-2598
  • 60 Roeseler J, Sottiaux T, Lemiale V. , et al. Prise en charge de la mobilisation précoce en réanimation, chez l'adulte et l'enfant (électrostimulation incluse). Reanimation 2013; 22 (02) 207-218
  • 61 Canadian Society for Exercise Physiology. Canadian Physical Activity Guidelines; Canadian Sedentary Behaviour Guidelines. Available at: http://www.csep.ca/cmfiles/guidelines/csep_guidelines_handbook.pdf
  • 62 Riner WF, Sellhorst SH. Physical activity and exercise in children with chronic health conditions. J Sport Health Sci 2013; 2 (01) 12-20
  • 63 Castro-Avila AC, Serón P, Fan E, Gaete M, Mickan S. Effect of early rehabilitation during intensive care unit stay on functional status: systematic review and meta-analysis. PLoS One 2015; 10 (07) e0130722 . Doi: 10.1371/journal.pone.0130722
  • 64 Kho ME, Martin RA, Toonstra AL. , et al. Feasibility and safety of in-bed cycling for physical rehabilitation in the intensive care unit. J Crit Care 2015; 30 (06) 1419.e1-1419.e5
  • 65 Dirks ML, Hansen D, Van Assche A, Dendale P, Van Loon LJ. Neuromuscular electrical stimulation prevents muscle wasting in critically ill comatose patients. Clin Sci (Lond) 2015; 128 (06) 357-365
  • 66 Odetola FO. Outcomes research in the PICU. Pediatr Crit Care Med 2014; 1: 107-116
  • 67 Lancaster GA. Pilot and feasibility studies come of age!. Pilot Feasibil Studies 2015; 1 (01) 1-4
  • 68 Guyatt GH, Schünemann HJ, Djulbegovic B, Akl EA. Guideline panels should not GRADE good practice statements. J Clin Epidemiol 2015; 68 (05) 597-600
  • 69 Carcillo JA, Fields AI. ; American College of Critical Care Medicine Task Force Committee Members. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med 2002; 30 (06) 1365-1378
  • 70 Munkwitz M, Hopkins RO, Miller Iii RR, Luckett PM, Hirshberg EL. A perspective on early mobilization for adult patients with respiratory failure: Lessons for the pediatric population. J Pediatr Rehabil Med 2010; 3 (03) 215-227