PS201 Week 7 Cue Cards - Early Mobilisation in Acute Care
Definition and scope of early mobilisation
In the acute care context, mobilisation means progressing toward locomotion, not just joint movement.- Pathway typically spans from lying supine in bed to sitting up, sitting out of bed, sitting in a chair, and walking away from the bed.
In other physiotherapy contexts (e.g., orthopaedics), “mobilisation” may refer to local joint movements; in acute care, it emphasises locomotion and functional progression.
Early mobilisation as usual care and practical examples
Early mobilisation is the standard care pathway for hospitalised patients.- Example protocol after major surgery (oesophagogastrectomy): aim for sitting on the edge of the bed, sitting in a chair, walking on the spot, walking away from the bed, and progressing to walking for periods up to >15\,\text{min}.
2017 Australian survey of physios involved in upper abdominal surgery:
On day 1 after surgery, nearly all expected to move the patient from bed to beside the bed, walk on the spot at the bedside, and most would have them walk >5\,\text{m} away from the bed.
Rationale: strong evidence supports early mobilisation as an effective and safe intervention.
Physiological rationale: oxygen transport pathway and mobilisation effects
Oxygen transport pathway (simplified): intake through airways -> lungs -> pulmonary circulation -> heart -> systemic circulation -> tissues. Mobilisation can improve or challenge multiple points along this pathway.- Supine to upright changes improve diaphragmatic descent and thereby enhance oxygen entry into the pathway.
Exercise increases tissue demand for oxygen, so clinicians must weigh the patient’s respiratory and cardiovascular reserves.
Key concept: balance between benefits and risks. Treat mobilisation as individualised, not a fixed recipe for every patient.
Summary of positioning effects on the cardiopulmonary system:- Supine to upright: improves tidal volume, lung compliance, and diaphragmatic excursion; helps mobilise secretions.
Upright to standing and walking: increases oxygen demand and requires adequate reserves to avoid intolerance.
Broader benefits beyond cardiopulmonary systems:- Musculoskeletal and neurological systems benefit from moving and loading (e.g., preventing deconditioning, maintaining strength, improving neuromotor control).
Caution: even though early mobilisation is beneficial, it must be matched to the individual’s reserve and stability; pushing every patient to the same targets can be dangerous.
Bed rest: when it is necessary and its historical context
There are clinical situations where short-term bed rest is appropriate to reduce symptoms or manage adverse events:- Post-spinal fracture immobilisation, extensive tissue grafting after burns, or after certain procedures.
After intravascular access procedures (e.g., line insertions) or after lumbar puncture; may require hours of rest.
Historical perspective on bed rest and evidence uptake:- 1944 JAMA quote emphasised that complete bed rest is highly unphysiologic and hazardous except for specific indications, and should be discontinued as early as possible.
Historical narrative: after a myocardial infarction (heart attack), bed rest was common for two months; this led to higher mortality from pneumonia and pulmonary embolism than from cardiac causes.
Uptake of evidence was slow: by the 1950s, four weeks of bed rest after MI was still common; current practice often allows rest up to ~12\,\text{hours} and allows sitting out of bed on the first day after MI when appropriate.
Takeaway: immobilisation has systemic downsides; upright position and mobility are physiologically protective for most patients, hence the emphasis on graded mobilisation.
Negative effects of immobilisation on body systems
General observation: many negative effects observed in immobilised patients, especially in hospital settings (often studied in young, healthy populations but applicable to patients).
Pulmonary effects of immobilisation:- Alveolar collapse/atelectasis, reductions in lung volumes, reductions in respiratory muscle strength.
These changes occur quickly, even after major surgery.
Cardiovascular effects:- Decreased total blood volume, changes in haemoglobin, reduction in cardiac size.
Blood becomes more viscous and venous return slows, contributing to risks such as deep venous thrombosis (DVT).
Musculoskeletal effects:- Muscle strength decline, connective tissue shortening, and potential for joint contractures (focus of immobility effects).
Other systemic effects:- Immobility is a pro-inflammatory state.
Emotional/behavioural changes, reductions in psychomotor performance, and sleep disturbances, especially pronounced in ICU patients.
Key note: pulmonary effects accumulate rapidly with immobilisation, underscoring the importance of early mobilisation when feasible.
Orthostatic intolerance and vasovagal responses during mobilisation
Orthostatic hypotension:- Definition: a drop in systolic blood pressure (SBP) of at least 20\,\text{mmHg} when moving from supine to upright.
Clinical signs of intolerance: light-headedness, dizziness, visual changes, feeling unwell.
Mechanism: after prolonged bed rest, the cardiovascular system has adapted to low effort; upright posture challenges perfusion to the brain until compensatory mechanisms kick in.
Vasovagal syncope (vasovagal response):- Mediated by vagal/parasympathetic pathways causing vasodilation and BP drop; can occur after surgery or emotional stress, pain, or trauma, sometimes without obvious triggers.
Symptoms: pallor, sweating, visual disturbances, near-fainting, or actual fainting.
Management: return to the supine position, assist, treat contributing factors as needed.
Practical implication: when mobilising, start gradually—sit on edge of bed, then progress to standing and marching near the bed, and only advance to a chair once tolerance is established.
Assessment and collaborative decision making before mobilisation
Central questions in the assessment:- What is preventing mobilisation? Symptoms, fear, pain, or other factors?
Do the potential benefits outweigh the risks for this patient?
Information sources for decision making:- Physiotherapist assessment (clinical status, stability, response to previous mobilisations).
Patient perspective (concerns, readiness, expectations).
Evidence base for mobilisation in the specific patient context.
Key physiological stability checks during assessment:- Cardiovascular reserve: blood pressure stability and perfusion to brain.
Respiratory reserve: adequate oxygen diffusion and gas exchange.
Musculoskeletal status: muscle strength, skeletal stability, coordination, and control.
Environmental and logistical considerations:- Other factors to assess before mobilisation (environment, infection control, temperature, etc.).
Weight-bearing status and any restrictions (e.g., after limb surgery).
Planning the transfer, explaining the plan to patient and staff, and ensuring appropriate assistance and equipment are available.
Case example: 70-year-old man after abdominal aortic aneurysm repair
Scenario: day 1 after major abdominal surgery (AAA repair).
Current status:- Oxygen via mask at 6\,\text{L/min}.
SpO₂ = 95\%.
Blood pressure = 100/50\,\text{mmHg}.
Heart rate = 85\,\text{bpm}, regular.
Epidural anaesthesia in place.
Cough: moist, weak; breath sounds at the bases are limited.
Decision considerations: weigh whether mobilisation is safe and likely to be beneficial given pulmonary findings and haemodynamic status.
Practical safety considerations for first mobilisation
Gather comprehensive information from multiple sources before mobilising:- Up-to-date cardiovascular and respiratory status, temperature, weight-bearing restrictions.
Coordination and staffing:- Check with nursing and ensure adequate assistance (e.g., two people) and required equipment close by.
Environmental readiness:- Ensure room and equipment are ready; stay close to the patient during transfer; have a wheelchair or chair prepared to accommodate limited distance if needed.
Safety checklist during mobilisation:- Continuously monitor observations and symptoms.
Adjust plan if signs of intolerance appear.
Remove obstacles and ensure safe pathways; prepare gait aids and ensure they are accessible.
Infection control and patient comfort:- Hand hygiene before and after patient contact; maintain privacy and comfort during the process.
Documentation and communication:- Document patient status and progress; verbally communicate plan to nursing staff and patient following the transfer.
Overall message: moving from bed to standing to walking involves complex planning across cardiovascular, respiratory, musculoskeletal, and environmental domains; ongoing practice and refinement occur in clinical courses and placements.
Summary and takeaways
Early mobilisation is the usual care pathway in hospital patients and is generally beneficial when tailored to the individual’s reserves and stability.
Mobilisation progresses from bed to edge of bed, to standing, to chair, and finally to walking, with gradual escalation based on tolerance.
Physiological rationale centres on improving diaphragmatic function, lung volumes, and secretions, while recognising the increased demands on the cardiopulmonary system during activity.
Immobilisation has broad deleterious effects across multiple organ systems, which supports prioritising safe mobilisation; however, bed rest remains necessary in select clinical scenarios.
A thorough, collaborative assessment—considering patient perspective, physiological stability, and environmental factors—guides safe and effective mobilisation in acute care.
Safety planning includes coordinating with nursing, ensuring equipment and assistance, optimising the environment, and monitoring patient status throughout and after transfer.
Revision prompts (based on content)
Define early mobilisation in acute care and contrast it with orthopaedic interpretations of mobilisation.
List the day-1 mobilisation targets reported in the oesophagogastrectomy protocol and the 2017 Australian survey findings (with numerical details).
Explain how sitting up and upright positions affect diaphragmatic excursion and tidal volume, and why these changes matter for oxygen delivery.
Describe orthostatic hypotension with its diagnostic criterion and typical symptoms to watch for during mobilisation. Include the quantitative threshold.
Distinguish orthostatic hypotension from vasovagal syncope and summarise their management when mobilising a patient.
Summarise historical bed-rest practices and the evolution to current recommendations (include the numeric timeline: 2\,\text{months} \rightarrow 2\,\text{weeks} \rightarrow 12\,\text{hours}).
Identify key components of a safe mobilisation plan for a post-operative patient (data to collect, how to proceed gradually, and safety measures).