3.3.2. Early Mobilization

Early mobilization shortens the out-of-bed period, the length of stay in the ICU, and the total hospitalization time [7]. Typically, phase I of cardiac rehabilitation following cardiac surgery is commenced in the intensive care unit (usually 2–3 days), then is continued in the cardiac surgery department (typically days 2–7). The mobilization of patients after cardiac surgery is complex, due to clinical instability and multi-organ dysfunction. Contributing factors include respiratory insufficiency; impaired cardiovascular system; skeletal muscle weakness; and the effects of medications, especially sedatives. Postoperative recovery and thus, early exercise prescription in patients after cardiac surgery is affected by the presence of many complications: persistent chest pain, shoulder discomfort, anemia, arrhythmias (typically atrial fibrillation), post-thoracotomy syndrome, phrenic nerve injury, sternum instability, delayed wound healing, cognitive dysfunction, sleeplessness, depression, and anxiety [27].

Early mobility in the intensive care unit is contraindicated in the case of [28]: Absolute contraindications:


Relative contraindications:


Despite the existence of supporting data for the safety of early mobilization in intensive care units, clinical practice differs, and the amount of rehabilitation offered is often insufficient. This might be because the assessments of health deficiencies are inaccurate. Utilizing existing tools—e.g., the International Classification of Functioning, Disability, and Health—has been strongly recommended for the precise evaluation of the level of cooperation, muscle strength, joint mobility, and functional status (using the Functional Independence Measure, Berg balance scale, Functional Ambulation Categories) prior to the commencement of early mobilization [29]. In the case of uncooperative, critically ill patients, body positioning (every 2 h), passive cycling (Figure 3), joint mobility, passive muscle stretching, and neuromuscular electrical stimulation can be applied [30]. Continuous passive motion prevents contractures and has been used in patients with critical illness and prolonged inactivity [31]. For those who cannot be actively mobilized and with a high risk of soft-tissue contracture—e.g., with some neurological conditions or after trauma—splinting may be recommended. A recent study demonstrated that the early application of daily bedside (initially passive) leg cycling in critically ill patients resulted in improved functional status and improved muscle function at hospital discharge compared to patients who did not receive leg cycling [32].

Neuromuscular electrical stimulation is applied in patients who cannot voluntarily perform muscle contractions to prevent muscle atrophy [33].

In the case of cooperative patients, the mobilization strategy includes transferring in bed, sitting over the edge of the bed, moving from the bed to a chair, standing, marching on the spot, and walking with or without support [34–37].

The Leuven protocol—i.e., the meticulous step-up approach for progressive early mobilization—has been recommended [35]. It includes six levels of mobilization based on cooperation status, assessed by responses to five standardized questions ("open and close eyes", "look at me", "open your mouth and stick out your tongue", "shake yes or no", "I will count to 5, frown your eyebrows afterwards"), cardiorespiratory status, the Berg balance scale, and the Medical Research Council muscle strength scale (Figure 4).

F3 **Figure 3.** Passive bedside cycling. Source: Reprinted from [35], used with permission. **Figure 2.** 'Start to move' – protocol Leuven: step-up approach for progressive mobilisation and physical activity program.

Furthermore, the training intensity can be continuously adjusted

The application of exercise training in the early phase of ICU


bilisation and physical activity program Open and close your eyes Look at me Open your mouth and stick out your tongue Shake yes and no (nod your head) 2 : FAILS = at least 1 risk factor present 1 needs minimal aid to stand or stabilize 0 needs moderate or maximal assist to stand STANDING UNSUPPORTED 4 able to stand safely for 2 minutes 3 able to stand 2 minutes with supervision **Figure 4.** The Leuven protocol. Abbreviations: BBS—Berg balance scale; MRC—Medical Research Council muscle strength sum scale; S5Q—response to 5 standardized questions for cooperation. Source: Reprinted from [35], used with permission.

2 able to stand 30 seconds unsupported

4 able to sit safely and securely for 2 minutes 3 able to sit 2 minutes under supervision 2 able to able to sit 30 seconds 1 able to sit 10 seconds

0 unable to sit without support 10 seconds

1 needs several tries to stand 30 seconds unsupported 0 unable to stand 30 seconds unsupported

SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR

ON A STOOL

1

BBS: Berg Balance Score SITTING TO STANDING

68 NETH J CRIT CARE - VOLUME 15 - NO 2 - APRIL 2011

3 able to stand independently using hands

I will count to 5, frown your eyebrows afterwards

3 : if basic assessment failed, decrease to level 0

4 : safety: each activity should be deferred if severe adverse events (cv., resp. and subject. intolerance) occur during the intervention MRC (Medical Research Council) muscle strength sum scale(0-60)

4 able to stand without using hands and stabilize independently

S5Q—responses to five standardized questions for cooperation:


BBS—Berg balance scale:

	- 4—able to stand without using hands and stabilize independently;
	- 3—able to stand independently using hands;
	- 2—able to stand using hands after several tries;
	- 1—needs minimal aid to stand or stabilize;
	- 0—needs moderate or maximal assistance to stand.
	- 4—able to stand safely for 2 min;
	- 3—able to stand for 2 min with supervision;
	- 2—able to stand for 30 s unsupported;
	- 1—needs several trials to stand for 30 sec unsupported;
	- 0—unable to stand for 30 s unsupported.
	- 4—able to sit safely and securely for 2 min;
	- 3—able to sit for 2 min under supervision;
	- 2—able to sit for 30 s;
	- 1—able to sit for 10 s;
	- 0—unable to sit without support for 10 s.

MRC (Medical Research Council muscle strength sum scale (0–60):

0—no visible contractions


Max score: 60 (4 limbs, 3 movements per extremity, with a maximum score of 15 points per limb)

Upper extremities: shoulder abduction/elbow flexion/wrist extension.

Lower extremities: hip flexion/knee extension/ankle dorsiflexion.

The authors recommend, as mentioned earlier, the use of the three-staged mobilization model described in Tables 19–21 (A2 and B models).


**Table 19.** Suggested first stage of early mobilization after cardiac surgery.

**Table 20.** Suggested second stage of early mobilization after cardiac surgery.


Source: Table by authors.


**Table 21.** Suggested third stage of early mobilization after cardiac surgery.

### *3.4. Home Activity after Hospital Discharge*

All eligible cardiac patients should be referred to cardiac rehabilitation after recovery from an acute cardiac event [8]. Notwithstanding that, the referral rate remains insufficient, and motivational strategies to enhance participation in cardiac rehabilitation programs and the provision of comprehensive information about the purposes and formats of cardiac rehabilitation are essential [38,39]. Many patients do not receive sufficient information about the exercise intensities allowed during their post-discharge period at home. Basically, prior to discharge, patients should attain a mobility level of approximately 3 METS, and they should be given a safe and progressive home exercise plan [40]. In some countries—e.g., in England—patients discharged from hospital are contacted by members of a cardiac rehabilitation team in the form of home visits, telephone calls, or outpatient appointments for education/health promotion classes; this period is described as the immediate post-discharge phase [41,42]. Post-discharge activities at home should aim to achieve a gradual increase in functional capacity. Patients are encouraged to walk in and around their homes and then to walk outdoors. Rates of perceived exertion or pulse should be assessed to monitor patients' exercise response. Prior to commencing a supervised exercise program, patients should be able to walk for about 30 min daily. Some specific limitations are imposed temporarily on patients after cardiac surgery. Efforts contraindicated for 12 weeks following cardiac surgery are those against high resistance or with a marked isometric aspect—e.g., lifting or moving heavy items; raising both arms for a long time above the head; and running, swimming, and skiing due to sternum stability concerns [43,44]. Sexual activities can be resumed 1–2 weeks after uncomplicated myocardial infarction without cardiac symptoms during mild to moderate physical activity, and optimally 6-8 weeks after cardiac

surgery (if patients can comfortably walk about 300 m on a flat surface or climb two flights of stairs briskly without chest pain or becoming breathless). Sexual activity is contraindicated in the presence of a low angina threshold and complex ventricular dysrhythmias [45].
