Original Article

Practice Recommendations for Early

Mobilization in Critically Ill Children
Karen Choong1,2 Filomena Canci3 Heather Clark3 Ramona O. Hopkins4,5,6 Sapna R. Kudchadkar7
Jamil Lati8 Brenda Morrow9 Charmaine Neu3 Beth Wieczorek7 Carleen Zebuhr10

1 Department of Pediatrics, McMaster University, Hamilton, Ontario, Address for correspondence Karen Choong, MB, BCh, MSc,
Canada Department of Pediatrics, Critical Care, Epidemiology and
2 Department of Health Research Methods, Evidence and Impact, Biostatistics, McMaster University, 1280 Main Street West,
McMaster University, Hamilton, Ontario, Canada Room 3 E-20, Hamilton, Ontario L8N 3Z5, Canada
3 Pediatric Intensive Care Unit, McMaster Children’s Hospital, (e-mail: choongk@mcmaster.ca).
Hamilton, Ontario, Canada
4 Psychology Department and Neuroscience Center, Brigham Young
University, Provo, Utah, United States
5 Division of Pulmonary and Critical Care Medicine, Intermountain
Medical Center, Murray, Utah, United States
6 Center for Humanizing Critical Care, Intermountain Healthcare,
Murray, Utah, United States
7 Department of Anesthesiology and Critical Care Medicine and
Pediatrics, Johns Hopkins University School of Medicine, Baltimore,

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Maryland, United States
8 Division of Rehabilitation, Department of Physical Therapy,
University of Toronto, The Hospital for Sick Children, Toronto,
Canada
9 Department of Pediatrics and Child Health, University of Cape
Town, South Africa
10 Department of Medicine, Pulmonary and Critical Care Division,
Intermountain Medical Center, Murray, Utah, United States

J Pediatr Intensive Care

Abstract 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
Keywords the overall goals of mobilization are to reduce PICU morbidities and optimize recovery. EM
► early mobilization should therefore not be instituted in isolation but as part of a rehabilitation care bundle.
► critically ill children Mobilization should not be delayed, but its appropriateness and safety should be assessed
► physiotherapy early. Increasing levels of physical activity should be individualized for each patient with the
► practice guidelines goal of achieving the highest level of functional mobility that is developmentally

received Copyright © by Georg Thieme Verlag KG, DOI http://dx.doi.org/

January 8, 2017 Stuttgart · New York 10.1055/s-0037-1601424.
accepted after revision ISSN 2146-4618.
February 23, 2017
Practice Recommendations for Early Mobilization in Critically Ill Children Choong et al.

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.

Introduction neurosurgical, cardiac surgical, and burns patients.16–19

However, there are currently no published rehabilitation
Pediatric intensive care unit (PICU) mortality rates have or physiotherapy practice guidelines specifically targeted
decreased in the last decade, however, the proportion of to the general PICU population. The objective of this article
children surviving their critical illness with significant func- was to develop clinical practice recommendations for safe,
tional morbidity is rising.1 Prolonged immobility is an mobility-based rehabilitation in critically ill children.
important predictor of poor functional outcome and the
development of critical illness-acquired morbidities.2
Methods
These morbidities, in turn, have important negative physical,

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neurocognitive, and mental health consequences in adults A group of 10 multidisciplinary experts with either clinical
and pediatric survivors of critical illness, that can persist long and methodological expertise in physical rehabilitation,
after these patients leave the intensive care unit (ICU) pediatric critical care and currently involved in research on
setting.3,4 Referred to collectively as the postintensive care early mobilization (EM) in critically ill patients were engaged
syndrome, this phenomenon affects up to 69% ICU survivors, to participate in developing clinical practice recommenda-
is often longlasting, negatively impacts patients’ quality of tions for the safe mobilization in PICU, using the Institute of
life, and represents a significant burden not only to the health Medicine framework.20 Participants were all from tertiary
care system, but to society at large.5 Post-PICU cognitive, care institutions and comprised of three pediatric intensiv-
psychologic, and functional sequelae is also increasingly ists, four physiotherapists, one nurse and research psychol-
recognized in critically ill children and their families.6 As a ogist, one quality improvement nurse, and one advanced
result, there is tremendous growth of research evaluating care practice nurse, from Canada (n ¼ 5), United States
interventions to prevent these critical illness sequelae. Mini- (n ¼ 4), and South Africa (n ¼ 1). Key principles agreed
mizing sedation, facilitating spontaneous breathing, and upon by the group were to define: (1) the goals of EM;
promoting early rehabilitation have been shown to be feasi- (2) what constitutes mobilization; (3) appropriate timing
ble, safe, and improves patient outcomes, and are therefore for mobilization; (4) clinical criteria for determining mobili-
now recommended as practice priorities amongst ICUs.7–9 zation readiness and safety, and (5) mobilization frequency
This approach, coupled with post-ICU follow-up and rehabil- and duration.
itation programs are increasingly adopted to optimize post- First, we conducted a systematic review of the literature.
hospital recovery in adult ICU survivors.10 We searched PubMed, CINAHL, and EMBASE from inception to
Unfortunately, pediatric research on ICU-based rehabili- October 2016, for observational studies, clinical trials or clini-
tation significantly lags behind adult evidence.11 The major- cal trial protocols, and practice guidelines focused on PICU-
ity of rehabilitation in critically ill children is nonmobility based mobility or physical therapy interventions conducted in
based.12–14 Only 9.5% of children admitted to Canadian PICUs the general PICU population aged younger than 18 years,
are mobilized early, within 48 hours of PICU admission.12 published in full or in abstract in any language. We manually
Major barriers to mobilizing critically ill children include searched the National Institutes of Health (available at: http://
resource limitations (i.e., the lack of dedicated physical or clinicaltrials.gov), and the Evidence in Pediatric Intensive Care
occupational therapy staff), limited awareness of existing Collaborative (available at: http://epicc.mcmaster.ca) for addi-
evidence, and the lack of practice guidelines specifically tional eligible studies. We excluded adult trials, case series or
for the PICU population.13,15 While clinicians agree that case reports, systematic and narrative reviews, and studies
prolonged bed rest is inappropriate, many express safety focused on nonmobility interventions or chest physiotherapy
concerns with mobilizing children.15 Subsequently, there are alone. The results of our search are presented in the ►Appendix .
diverse opinions regarding if, when and how to mobilize We used this evidence to answer the clinical questions where
children in the PICU. possible and appropriate, however, where there was a paucity
Mobility-based rehabilitation initiated early during criti- of pediatric evidence, we utilized adult ICU randomized trials,
cal illness and continued after discharge has been suggested systematic reviews, and practice guidelines for additional
to improve patient outcomes, particularly in adult ICU, and safety data on EM.21–27 We summarized the best level of
specific pediatric populations such as premature neonates, evidence supporting our recommendations using the Oxford

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 Practice Recommendations for Early Mobilization in Critically Ill Children Choong et al.

Centre of Evidence-Based Medicine (OCEBM) 2011 guidelines, and is therefore recommended by the Society of Critical
where level 1 represents systematic review of randomized Care Medicine ICU Liberation Campaign (available at:
trials, level 2 represents randomized trial or observational www.iculiberation.org). Integrating these practices in the
study with dramatic effect, level 3 represents cohort studies, PICU may similarly reduce iatrogenic morbidities and
level 4 represents case series or case–control studies, and level improve outcomes and recovery in critically ill children,
5 indicates mechanism-based reasoning.28 We considered the however, there is currently little pediatric evidence support-
strength and quality of the available evidence alongside po- ing this approach. Family-centered care is now considered
tential benefits and harms when making our safe practice “best practice” and essential for a child’s recovery from
recommendations. Using an iterative process, the working critical illness.31 Promoting family engagement and partner-
document was circulated electronically to panel members ship in a rehabilitation care bundle increases awareness
until the group reached consensus, defined as 100% agree- and positively impacts practice.32 We added “G” for “Good
ment. The consultation was sought from key stakeholders in nutrition” to this bundle, to emphasize that nutrition is a key
the PICU and the subspecialty services whose patients may be component to optimizing functional recovery during critical
cared for in the PICU such as neurosurgery, otolaryngology, illness.33 We promote “H” for “Humanism,” as a reminder to
orthopedic surgery, plastic surgery, and general surgery. We clinicians of the negative effects of the critical care setting,
solicited their input through the respective division leaders, on and of the depersonalization of patients which is unfortu-
contraindications, precautions, and appropriate levels of mo- nately now commonplace in our technology-dependent
bilization in their critically ill pediatric population. The guide- environment.34 We recommend strategies to foster more
lines were then piloted at a single center over a 12-month personal and humane care, and to create an environment
period (McMaster University), during which time informal where healing and recovery are possible.35
feedback was obtained from bedside nurses, physicians, phys-

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iotherapists, and the subspecialty division leaders, on the
What Constitutes “Mobilization” in the Critically Ill
sensibility and feasibility of the practice recommendations.
Child: Graded Mobilization Activities and Goals
Recommendation
Results To optimize safe mobilization while minimizing the adverse
events, we recommend that critically ill children progress
The Goals of Early Mobilization: A Bundled Approach
through a range of graduated activities that are developmen-
Recommendation tally appropriate, individualized, and at its lowest level
The consensus group agreed that the overall goals of mobili- serves to prevent muscle wasting, and advances as the goals
zation in critically ill children are to improve functional of care transition to achieving functional mobility and in-
recovery and reduce the length of PICU and hospital stay. creasing muscle strength.
We, therefore, recommend that EM be instituted as a part of
an “ABCDEFGH” rehabilitation care bundle: Rationale
There is level 1 evidence suggesting that compared with
• Attention to Analgesia; Avoid oversedation; allow
other interventions, exercise and mobility-based physical
Awakening
therapy is the most effective intervention in optimizing
• Spontaneous Breathing trials
functional recovery in critically ill adults.16 However, to
• Choice of sedation and analgesia
date, there is only level 3 evidence describing mobilization
• Delirium prevention, surveillance, and management
interventions, and randomized trials underway in pediat-
• Early mobilization and Exercise
rics.14,21,36–40 These studies do not clearly define degrees of
• Family engagement and empowerment
mobilization activities in the critically ill pediatric popula-
• Good nutrition
tion. While ambulation and independent mobilization out of
• Humanism
bed are often the endpoints in adults, this is often not feasible
Rationale in children given the heterogeneous age, cognitive and
Mobilization is a rehabilitation intervention to prevent criti- baseline function of this population. The group, therefore,
cal illness-acquired morbidities, such as muscle weakness agreed that what constitutes “functional mobility” for a child
and deconditioning, while optimizing skin integrity, physi- should, therefore, be individualized and developmentally
cal, and neurocognitive health, decrease the duration of appropriate; this may vary from sitting tolerance in chronic
advanced life-support and PICU length of stay, and ultimately wheelchair users to neurodevelopmental play in infants.
to enhance functional recovery. Hence, mobilization strate- We developed taxonomy for physical therapy activities for
gies can only be effective if supported by a patient-centered the purpose of ensuring clarity, defining levels of mobility,
care bundle. The ABCDEF bundle incorporates a set of identifying individualized patient goals, and facilitating con-
evidence-based practices that address several emerging sistency in language and documentation (►Table 1). The level
serious ICU-acquired morbidities such as ventilator pneu- of mobilization should be determined by the physiotherapist’s
monia, weakness, delirium, and functional disability.29 The clinical assessment of the patient in conjunction with input
use of such a bundle in critically ill adults can result in from other clinicians, as well as an assessment of safety. Given
significant improvements in patient care and outcomes,30 the heterogeneous population of children admitted to PICUs,

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Practice Recommendations for Early Mobilization in Critically Ill Children Choong et al.

Table 1 Definitions of mobility and nonmobility interventions in critically ill children

Intervention Description
Nonmobility
Bed repositioning only Activity restricted to passive position changes in bed
Respiratory or “chest physiotherapy” Physical methods to improve: Ventilation and V/Q matching, breathing
mechanics, respiratory muscle strength and airway secretions clearance,
e.g., chest wall vibrations, percussion techniques, manual facilitation of
chest wall movement, manual or ventilator hyperinflation, deep
breathing exercises (including blowing bubbles and incentive
spirometry), and inspiratory muscle training
Passive range of motion and stretching exercises The therapist moves joints and stretches muscles through their full
available range of motion to prevent or correct tightening of muscles or
joints, which could lead to contracture formation
Mobility
Active range of motion and stretching exercises Active movement of patient’s limbs through an available range of joint
(“AROM” or “AAROM”) motion. These movements can be independently done by patient (active
Strengthening exercises ROM; “AROM”), active stretching (patient uses opposing muscle group to
stretch affected group), or the patient may need assistance to complete
the full available joint range (active-assisted ROM; “AAROM”)
Exercises to place a load on muscles to achieve greater muscle strength,
e.g., by a patient actively moving a weak limb against gravity; by the

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therapist providing manually graded resistance to movement; by
applying tension to cycling on the ergometer
Neurodevelopmental play Goal-directed activities to maintain or improve fine and gross motor
development, muscle strength, thoracic mobility, coordination and
balance for infants, and developmentally delayed children
Mobility device (e.g., in-bed cycling) Activities are done with a device that facilitates functional limb
movement, the range of motion, and strengthening, e.g., cycle
ergometer. May be active or passive and executed in the supine patient.
May be conducted in lower or upper limbs
Bed mobility Functional activities are done while patient is recumbent in bed, but
require the active participation of the patient; e.g., active or
active-assisted repositioning in bed; rolling from side-to-side; and
bridging (i.e., supine with pelvic or hip lifts), does not involve moving out
of bed or over the edge of the bed
Transfers These activities may be active or passive, may occur with varying degrees
of caregiver assistance and supervision, or may be performed
independently
Transfer from lying to sitting at edge of bed Sitting at edge of bed, with or without caregiver support as needed
Transfer from bed to/from chair Transfers from bed to chair, wheelchair or a neurochair, using a
mechanical lift, sliding board, caregiver assistance through patient
pivoting, stepping or shuffling to the chair/wheelchair or commode
Transfer from sitting to/from standing The patient can get up from sitting to/from standing with supervision or
assistance
Sitting tolerance Patient tolerates transfers from bed to a bedside chair or wheelchair and
can tolerate sitting tilted or upright, for periods of time (i.e., for at least
30 min)
Crawling Crawling with/without assistance
Pregait activities Exercises before ambulation, conducted with or without assistance, e.g.,
moving from seated to a standing position, weight shifting from foot to
foot, stepping in place, and sideways stepping
Ambulation Walking away from bed or chair (i.e., on each foot) with or without
assistance from a therapist or a gait aid (e.g., walker)
Activities of daily living For example, face washing, oral hygiene, dressing. May occur with varying
degrees of caregiver assistance

Abbreviations: AROM, active range of motion; AAROM, active assisted range of motion; ROM, range of motion; V/Q, ventilation/perfusion.
Note: Passive: No effort by the patient.
Assisted: Some active participation by the patient and with the help of a therapist or assistant.
Active: Some active participation (full to partial) by the patient with or without the help of a therapist.

Journal of Pediatric Intensive Care

 Practice Recommendations for Early Mobilization in Critically Ill Children Choong et al.

we recommend that progressive mobilization goals should be Rationale

individualized for each patient daily, corresponding to their Skeletal muscle wasting has been demonstrated to occur early
clinical condition, developmental maturity, strength, and en- and rapidly in adults in the first week of critical illness, and is
durance. We have organized mobilization activities according more pronounced amongst those with multi- versus single
to three levels of assistance required, that graduate from a organ failure.42 The benefits of mobilization appear to be
minimum goal of preventing muscle wasting, maintaining optimized with earlier initiation, while delays in mobilization
range of motion, and optimizing circulatory flow (level 1), to are associated with increasing morbidity in adults.16 However,
mobility activities that enhance strength, endurance, balance, a recent trial suggests that very EM within 24 hours specifically
and functional mobility (levels 2 and 3; ►Table 2). Even passive in adult stroke patients, is not recommended.43 A recent meta-
mobilization has the potential to activate muscle contraction analysis that categorized “late” as greater than 7 days, and
and has been shown to be beneficial.41 As the level of assistance “early” as less than 7 days, reported conflicting results. While
required improves over time, the activity goals may progress to earlier studies demonstrated improved functional mobility
encourage increasingly active patient participation, to achieve with EM interventions,44,45 more recent, larger trials have
the highest level of physical activity that is safe, age appropri- added controversy on its effect on longer term functional
ate, and functional for that patient. It is acknowledged that outcome and health-related quality of life in the adult popula-
some patients have significant baseline functional limitations tion.46–48 Potential sources of inconsistent findings in these
that may never allow them to progress to higher levels of trials to date include the delayed onset (i.e., 4–8 days from
activity. Hence, optimizing passive mobilization activities for admission), duration and intensity of mobilization, and select-
those who require level 1 or maximum assistance to facilitate ed outcome measures of physical mobility and strength which
their recovery to baseline, and identifying what functional are not necessarily predictive of “function.” Further pilot and
mobility for each patient is, should be individualized. ongoing trials seek to evaluate the “dosage, ” that is, the

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intensity and timing of EM, and a multiprong approach to
“rehabilitation” in the adult population.49–51
Appropriate Timing for Early Mobilization in Critically
In the pediatric critical care setting, EM was defined by
Ill Children
Wieczorek et al in their quality improvement project as
Recommendation within the first 3 days of critical illness.38 Pediatric interven-
Critically ill children should be assessed for appropriate tional studies enrolled children who were within 24 to 96
activity within 24 hours of PICU admission. hours of fulfilling eligibility (level 3 evidence),14,21,39,52 and

Table 2 Activity goals

Level of Definition Activity goalsa

assistance
1 Maximum • Patient requires full/near full support from • PROM
the caregiver (i.e., 75–100% assistance) • In-bed cycling (passive)
with the particular activity. This includes • Passive transfers to chair, manual or with mechanical lift
patients who are sedated, noncompliant,
or cannot volitionally participate with the
activity, and/or who can only participate
passively or minimally with the particular
activity
• Precautions present

2 Moderate • The patient requires a moderate-to-signif- • AROM/AAROM, stretching, and strengthening exercises
icant amount of support (25–75% assis- • Bed mobility
tance) with the activity, but can actively • In-bed cycling (active or active-assisted)
participate to a degree • Transfer lying to/from sitting EOB
• Precautions present • Transfer sitting to/from standing
• Transfer bed to/from chair
• Increasing sitting tolerance
• Pregait activities
• Ambulation
• Activities of daily living
• Developmental play

3 Minimum • The patient can actively participate in the •

activity but requires some assistance (less
than 25% assistance) and supervision

Abbreviations: AROM, active range of motion; AAROM, active assisted range of motion; EOB, edge of bed; PROM, passive range of motion.
a
To be individualized, according to the patient’s level of assistance required, the presence of precautions and functional level.

Journal of Pediatric Intensive Care

Practice Recommendations for Early Mobilization in Critically Ill Children Choong et al.

ongoing registered trials define “early” as within 48 hours of hence each case should be discussed individually, and precau-
critical illness, or when safety criteria are met following tion exercised during mobilization. As the clinical status of
PICU admission.37,53 Based on the current evidence, we were each critically ill patient is often dynamic, safety should be
not able to determine the impact of time from admission to assessed before, and during each mobilization event. We
first mobilization session on functional outcomes, or clearly, developed a safety checklist for use before the initiation of
define what constitutes “early” for mobility activities in mobilization (►Table 4), and a set of safety criteria for sus-
critically ill children. Ongoing pediatric and adult trials pending or aborting mobility physical therapy (►Table 5).
will provide important information on the most appropriate
timing and “dosage” of mobilization in critically ill patients
Mobilization Frequency and “Dosage”
in the future.49,51,54 Our recommendations are therefore
based on the strength of evidence that prolonged immobili- Recommendation
zation is harmful and should, therefore, be avoided.42,55,56 The nature of mobilization activities should focus on achiev-
We, therefore, emphasize that the timing of assessment for ing age-appropriate functional tasks, while the duration and
mobilization should be early, within the first 24 hours of frequency depend on the patient’s underlying condition. We
admission, and that readiness be determined according to suggest a goal of at least 30 minutes, once a day or in divided
the clinical and safety criteria recommended below. intervals, with the aim of increasing duration, frequency,
and/or intensity according to the child’s tolerance, response,
and individualized functional activity goals as outlined
Criteria for Determining Early Mobilization Readiness
in ►Table 2. Prescriptions for mobilization should be reas-
and Safety
sessed regularly, and be conducted in consultation with a
Recommendation qualified therapist. Therapists may prescribe a combination

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We recommend that the decision to initiate and advance of activities such that the patient is mobilized as many times
mobility be individualized for each patient, guided by clinical a day as possible as is safe. To facilitate this in a limited
judgment, and involve an interprofessional team that in- resource setting, where appropriate, therapists may engage
cludes therapists who are knowledgeable in mobilizing bedside caregivers (i.e., nurses, family members) in patient
patients, and the clinicians who have ultimate responsibility mobilization activities.
for decision-making in the patient’s overall care.
Rationale
Rationale Duration and intensity of activity are relevant to adequate
EM has consistently been shown to be safe in critically ill adults physical, motor, and cognitive growth. Around 60 minutes
including those requiring vasoactive infusions, mechanical daily or 250 minutes a week of moderate to vigorous-
ventilation, and invasive indwelling devices.24,50,57 Evidence intensity physical activity is recommended for healthy chil-
on the safety of EM in critically ill children is derived from dren, while 150 minutes a week is recommended in adults.61
observational studies (level 3),12,21,23,38,39,58,59 or are opinion Recommendations in the setting of acute or chronic illness
based.60 This evidence to date demonstrates that EM is safe and are variable.62 The dose response or frequency of mobiliza-
feasible in critically ill children receiving mechanical ventila- tion that is most efficacious in preventing morbidity and
tory support, invasive monitoring, sedative and vasoactive optimizing functional recovery in critically ill patients is
infusions. Based on these data, we developed a system-based currently unclear.63 The evidence from adult trials suggests
set of clinical safety criteria that prioritizes maintaining that a minimum of 30 and up to 60 minutes a day is
cardiorespiratory and neurologic stability and preventing safe.48,49,63,64 Our review of the pediatric evidence revealed
patient discomfort and device dislodgement (►Table 3). Con- that novel interventions such as in-bed cycling have been
ditions at highest risk of adverse events even during bed rest, safely instituted in the range of 10 to 30 minutes, once to
therefore, constitute contraindications to any mobilization twice per day (level 3).21,36,37,54 There is currently no evi-
until more evidence is available. Patients with conditions listed dence regarding the intensity of mobilization that is ideal for
as “precautions,” may be mobilized according to the level of all critically ill adults or children. We, therefore, graded
assistance required, but to exercise caution particularly when intensity in this population according to whether an activity
there are specific considerations, for example, fresh postoper- is passive, active-assisted or actively applied (►Table 2).
ative patient, mechanical ventilation, muscle paralysis. We There are benefits to passive mobilization in patients who
included “acute spinal cord injury” and “strict spinal precau- cannot actively participate, such as the prevention of skeletal
tions” as precautions, to remind clinicians when possible, it is muscle atrophy, and the preservation of joint mobility and
important to continue to mobilize the patient’s limbs while arterial function.41,65 This is particularly relevant in children
maintaining in-line spinal stabilization. Select pediatric pa- where the population is heterogeneous in age, cognitive and
tients may participate in active rehabilitation and ambulate functional ability, and subsequently cannot always comply
while on venovenous extracorporeal membrane oxygenation, with activities.
in the context of a well-organized multidisciplinary pro- We summarize our recommendations in ►Fig. 1. We used
gram.23,59 There was no consensus agreement on threshold a “traffic light” color-coded system: red to denote contra-
doses of vasoactive infusions or degree of invasive mechanical indications, amber to denote precautions and safety thresh-
ventilator support for which mobilization is contraindicated, olds, and green to denote mobilization activities should

Journal of Pediatric Intensive Care

 Practice Recommendations for Early Mobilization in Critically Ill Children Choong et al.

Table 3 Contraindications and precautions to mobilization in critically ill children

Contraindications (Not safe to mobilize, bed repositioning only)

Hemodynamic instability • Hypotension (blood pressure persistently below patient’s target causing end-organ
hypoperfusion)
• Ongoing need for fluid resuscitation and/or escalation in vasoactive medication
• Suspected/confirmed acute unstable or uncontrolled arrhythmia
• Evidence of cardiac tamponade (untreated)
• Acute cardiac ischemia (symptomatic and/or confirmed ECG changes)—not resolved
• Acute systemic or pulmonary hypertensive crisis—not resolved and/or requiring IV
antihypertensive therapy

Respiratory instability • Acute, impending respiratory failure, ongoing escalation in respiratory support, and/or
endotracheal intubation is anticipated within the next 4 h
• Escalating intravenous bronchodilator, intravenous or inhaled pulmonary vasodilator therapy
within last 4 h
Note: Stable titration and or weaning of respiratory support and Fio2 requirements even if high,
are not absolute contraindications to mobilization

Neurological instability • Evidence of, or high suspicion for acute cerebral edema, or active management of elevated
ICP with CPP not within target range
• Sudden, unexplained acute deterioration in level of consciousness
• Active uncontrolled seizures, or refractory status epilepticus exacerbated by active or passive
mobilization activity (documented)

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Surgical • Uncontrolled major, active bleeding
• Unstable or unstabilized pelvic or spinal fracture
• Acute surgical emergency

Precautions (special care, resources, and attention are required during mobilization of these patients)
Cardiovascular • Patients are receiving vasoactive infusion(s): Stable or weaning doses of vasoactive agents is
not an absolute contraindication to mobilization. There is no consensus agreement on
threshold doses for which mobilization is contraindicated, hence each case should be
discussed on a case by case basis, with consideration of individual patient and combination of
vasoactive drug(s)
• Systemic or pulmonary hypertension

Respiratory • Patients receiving invasive or noninvasive mechanical ventilation

• Patients with accessory muscle use and high oxygen requirements (i.e., Fio2 over 0.5)
• Status postairway reconstructive surgery or fresh tracheostomy
• Prone positioning during mechanical ventilation

Neurological/neurosurgical • Status postcraniectomy

• External ventricular drain/intracranial pressure monitor in situ
• Acute spinal cord injury
• Patients who are on neuromuscular blockers or present with acute muscle paralysis

Orthopedic/musculoskeletal • Strict spinal precautions in place (inline immobilization required)

• Limb fractures, osteopenia
• Joint laxity, hypotonicity or spasticity, specific regional/joint considerations

Other • Invasive lines/catheters in situ

• Continuous renal replacement therapy
• Specific requirements/instructions following surgery, e.g., status postskin grafts/muscle
flaps, open abdomen, risk of wound dehiscence
Note: These patients may have head of bed elevated and in-bed limb mobility as long as dressing
seal or wound integrity can be maintained

• Visceral organ injury (e.g., high-grade liver or splenic laceration)

• Uncontrolled agitation and/or pain, confusion, or delirium
• Bleeding diathesis
• Risk of postural hypotension/autonomic dysreflexia

Abbreviations: CPP, cerebral perfusion pressure; ECG, electrocardiogram; IV, intravenous.

Journal of Pediatric Intensive Care

Practice Recommendations for Early Mobilization in Critically Ill Children Choong et al.

Table 4 Premobilization safety checklist (for patients with precautions present)

& No contraindications present

& Precautions reviewed
& PT/OT has assessed the patient and set target activity goal(s)
& Activity order and goals reviewed with the team (i.e., health care team, family, and patient, where possible)
& Personnel required for mobilization available, e.g., PT, RN, and RT in patients requiring respiratory support
& Airway and lines secured, dressings intact
& Patient’s analgesia and comfort is optimized (target as determined by the medical team, using institutional guidelines)

Abbreviations: MD, medical doctor; OT, occupational therapist; PT, physiotherapist; RN, registered nurse; RT, respiratory therapist.

proceed. In order and foster a collaborative team approach to randomized controlled trials to determine the most effective
operationalizing these EM recommendations, we encourage rehabilitation strategy for critically ill patients.67 Subse-
the following three steps and questions to be assessed for quently, there is tremendous interest in not only preventing
each patient, every day. Step 1: Is it safe to move the patient? critical illness-acquired morbidities, but optimizing physical
Step 2: What is the activity goal and what is the safe level and mental health, and functional recovery in adult and
of activity for the patient? Step 3: When can we mobilize pediatric survivors of critical illness.
the patient, when the safety criteria are met? Feedback A key barrier to acute rehabilitation within the PICU is
from the stakeholders during the pilot phase allowed us to physician discomfort and knowledge on what is appropriate,

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assess the sensibility of the listed precautions and contra- safe, and timely in this population.12 As a result, bed rest
indications, and to determine if following such guidelines and prolonged immobility is the current standard in many
was feasible. PICUs.12,14 These practice recommendations incorporate cur-
rently available prospective efficacy, safety, and feasibility
evidence, and consensus expert opinion that promotes a
Discussion
safe, bundled approach with a goal of minimizing morbidity
Functional recovery is a patient-centered outcome and is and optimizing functional recovery in critically ill children.
increasingly identified as a priority in critically ill children.66 They raise awareness of the risks associated with immobility,
Rehabilitation has become a part of the adult ICU paradigm, prompt PICU clinicians to screen and assess their patients
and EM is now recommended as part of usual practice early, and serve to enhance communication in a collaborative
for critically ill adults.26 The National Institute for Health approach to patient-centered care, and encourage family
and Care Excellence clinical guidelines on rehabilitation engagement. We consider mobilization as therapy and a
after critical illness, identified the need for high-quality targeted goal and encourage scheduling rehabilitation into

Table 5 Safety and tolerance criteria for interrupting, altering, or aborting mobilization therapy

Cardiorespiratory instability • Persistent desaturation below target despite increase in Fio2

• Change in baseline in resting HR, mean BP or RR more than patient target or preset alarm limit
• New onset arrhythmia
• Acute signs of respiratory distress: new onset/increase in accessory muscle use, stridor or
wheezing, or poor air entry
• Concern for airway integrity
• Escalation in mechanical ventilator respiratory support
• Marked ventilator dysynchrony

CNS • Increase in ICP by 20% and/or > 20 mm Hg, and/or CPP below target
• Patient increasingly uncomfortable, agitated or combative that cannot be resolved with
nonpharmacological or pharmacological methods

Skin, wound, and joints • Concern for wound, skin, or joint integrity

Device • Concern for device integrity or dislodgement

Patient • Patient fall

• Patient discomfort

Abbreviations: BP, blood pressure; CPP, cerebral perfusion pressure; HR, heart rate; ICP, intracranial pressure; RR, respiratory rate; Spo2, peripheral
capillary oxygen saturation.
Note: Occurrence of these events prompt an interruption, rest as appropriate, and reassessment of ability to continue with the same mobility plan, or
readjustment to another mobility type and level.

Journal of Pediatric Intensive Care

 Practice Recommendations for Early Mobilization in Critically Ill Children Choong et al.

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Fig. 1 Early mobilization recommendations for critically ill children. We used a “traffic light” color-coded system: Red to denote contra-
indications, amber to denote precautions and safety thresholds, and green to denote mobilization activities should proceed. AAROM, active
assisted range of motion; AROM, active range of motion; BP, blood pressure; CPP, cerebral perfusion pressure; EVD, external ventricular drain;
Fio2 , fraction of inspired oxygen; HR, heart rate; ICP, intracranial pressure; OT, occupational therapist; PROM, passive range of motion; PT,
physiotherapist; WOB, work of breathing.

the daily goals of care for critically ill children. Our aim was to agreement of good practice statements; we therefore con-
alleviate the apprehension around mobilizing critically ill sciously chose not to apply the Grading of Recommendations
children, and encourage the safe progression from the lowest Assessment, Development and Evaluation (GRADE) method-
level to higher levels of mobility as the patient gains strength ology inappropriately, given the low quality of existing
and endurance. We, therefore, provide recommendations evidence.68
for advancing from passive to active mobilization, as our There are several limitations to these recommendations.
pediatric population is heterogeneous, and may have limited The most obvious are the paucity of pediatric evidence in this
ability to actively participate in exercise at best. These recom- field. While our recommendations on safety are supported
mendations serve as a guide and should always be used in the by prospective pediatric data, due to the lack of clinical trial
context of specific individualized patient considerations, and evidence, we acknowledge that our recommendations on
in conjunction with an interprofessional team. the timing and “dosage” of mobilization are therefore largely
The strengths of this article are that these practice recom- opinion based. We, therefore, supported our recommenda-
mendations were developed: (1) through the engagement of a tions where possible with safety criteria from ongoing
multidisciplinary group of experts with clinical and methodo- registered trials and evidence from adult trials. Until more
logical expertise in adult and pediatric rehabilitation; (2) pediatric-specific evidence emerges, we cannot make any
guided by the Institute of Medicine framework for developing recommendations as to which types of patients may benefit
clinical practice guidelines; (3) supported by currently avail- most from EM, nor if EM indeed improves outcomes in all
able evidence obtained through a systematic review of the critically ill children. These guidelines are targeted at a
literature; and (4) refined through an iterative process that general medical-surgical PICU population, and not specific
engaged other clinician stakeholders. The process of piloting subgroups of critically ill children with unique rehabilitation
the guidelines allowed us to receive key feedback on the needs. Our objective is to promote a culture of safety while
feasibility of its implementation. Also, it allowed us to refine guiding a goal-oriented collaborative approach to minimize
safety criteria, and upgrade some contraindications to pre- critical illness-acquired morbidities and optimize functional
cautions when clinicians began to understand that it is safe and recovery. Finally, while we recommend EM as only one
important to begin in-bed mobility even in children who component of a bundled approach to rehabilitation in criti-
were traditionally perceived as “too unstable to move” or cally ill children, our assessment of the evidence and practice
on significantly advanced life support. We emphasize recommendations focused only on mobilization, as this was
that our consensus recommendations are based on panel the primary objective of this article.69

Journal of Pediatric Intensive Care

Practice Recommendations for Early Mobilization in Critically Ill Children Choong et al.

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Journal of Pediatric Intensive Care

Appendix

Systematic review PRISMA flow diagram: studies of early mobilization in critically ill children

Records identified through Additional records identified

database searching through other sources
Idenficaon

(n = 1015) (n = 277)

Duplicates removed
(n = 185)

Titles and Abstracts

Screening

screened
(n = 1107)

Downloaded by: Tufts University. Copyrighted material.

Records excluded
(n = 1026)

Full-text articles
assessed for eligibility
Eligibility

Full-text articles excluded, with reasons

(n = 81) (n = 72):
37 Non-PICU population/setting
9 Non-mobility intervention
2 Qualitative descriptive
2 Case series/report
14 Narrative review
4 editorial/ commentary
3 available in abstract only
1 Systematic Review
Included

Studies included in qualitative synthesis (n=9)

4 Prospective cohort study19,34,36,37
1 Practice guidelines58
2 Retrospective studies10,38
2 Registered trials51, 52