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Running head: EARLY MOBILIZATION FOR BRAIN INJURY

Improving Cognitive Impairment in Patients with Traumatic Brain Injury Through Early

Mobilization: Clinical Implications

Alex Wheeler

Azusa Pacific University

GNRS: 507 Scientific Writing

Gee Y. Dugan, MSN, FNP-C

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There is significant research suggesting early mobilization is best practice for traumatic

brain injury (TBI) patients in the intensive care unit (ICU). However, approximately 35% are not

receiving early mobilization (Osborne, 2018). The research articles in this literature review will

investigate the following question: In critically ill patients with primary neurologic injuries, does

early mobilization result in reduced ICU length-of-stay and improved functional recovery,

demonstrated in mobility level and clinical neurological scales, compared to standard protocol of

bed rest? For the purpose of the PICOT question, clinical scales including Glasgow Coma Scale

(GCS), Early Rehabilitation Barthel Index (ERBI), Functional Ambulation Classification (FAC),

and Functional Independence Measure (FIM) will be utilized to assess functional recovery.

Background

In patients with TBI, primary neurologic brain injury can be defined as direct trauma to

the brain (Common Classifications of TBI, n.d.). This injury could include skull fracture,

epidural and subdural hematoma, contusion, concussion, shearing injury, or subarachnoid

hemorrhage. In patients with TBI who are admitted to the ICU, immobility has been the standard

of care which includes prolonged bed rest, time on a ventilator, and extended periods of sedation

(Medtronic, 2018; Moyer et al., 2017). All can lead to devastating effects on each functional

system in the human body (Medtronic, 2018). Eighty percent of patients in the ICU develop

neuromuscular and functional impairment, also known as ICU-acquired weakness (Medtronic,

2018). According to Medtronic (2018), 23% of ICU patients receiving standard bed rest protocol

after one year of discharge reported to have functional deficits.

Research shows that ICU patients completing early mobility programs within 1-week of

ICU admission, had shortened ICU stays and improved functional recovery based on clinical

neurologic scales including GCS, ERBI, FAC, and Functional Independence Measure (Bartolo
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et al., 2017; Hopkins et al., 2016; Klein, Mulkey, Bena, & Albert, 2015; Medtronic, 2018;

Waleed, et al., 2018). Patients who meet the qualifications for early mobility include those who

are (a) fully conscious, (b) able to communicate, and (c) without sedatives or muscle relaxants

(Waleed et al., 2018). Patients can be mechanically ventilated, without sedation or paralytics, but

must maintain an oxygen saturation of 95%. Patients who require complete bed rest do not

qualify for mobility. Although each hospital approaches early mobility programs differently, all

early mobilization protocols include progressive mobility beginning with basics such as passive

range of movement (PROM) of the four limbs, and progress to ambulating, with or without

assistance (Klein, Mulkey, Bena, & Albert, 2015; Waleed, et al., 2018).

Literature Review

To obtain information regarding early mobility in critically ill patients with primary

neurologic injury, a review was performed using CINAHL. The search terms used for inclusion

criteria were: early mobilization, early ambulation, traumatic brain injury, primary neurologic

injury, and critical care. A total of 876 articles were populated in CINAHL. Articles that were

older than 2015 and non-English articles, as well as those that focused on patients in the general

ICU versus neurological ICU were excluded. Articles focusing on early mobility compared to

standard protocol of bed rest were chosen. Based on the above inclusion and exclusion criteria,

eight articles were selected for analysis. Per the level of hierarchy by Dearholt and Dang (2017),

four of the articles were level II (Demir et al., 2019; Klein et al., 2015; Moyer et al., 2017; Okada

et al., 2019), two were level III (Bartolo et al., 2017; Rocca et al., 2016), and two were level V

(Stam & Fernandez, 2017; Waleed et al., 2018). The eight articles selected will be reviewed to

determine support for the PICOT question.

Population/Sample
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Participants in all studies had severe acquired brain injury including skull fracture,

epidural and subdural hematoma, contusion, concussion, shearing injury, or subarachnoid

hemorrhage (SAH; Bartolo et al., 2017; Demir et al., 2019; Klein et al., 2015; Moyer et al., 2017;

Okada et al., 2019; Rocca et al., 2016; Stam & Fernandez, 2017; Waleed et al., 2017). However,

one study excluded participants with specific neurological diagnoses such as neurological

disease and neuroplastic disease with metastases (Bartolo et al., 2017). Patients enrolled in the

studies were fully conscious, able to communicate, not under the influence of sedatives or

muscle relaxants, at least 14 years of age, and able to maintain an oxygen saturation of at least

95%. Participants were excluded from all studies if they required complete bed rest. Sample size

ranged from a single participant case study to 1,322 TBI patients (Okada et al., 2019; Stam &

Fernandez, 2017). Although the single participant case study did not allow for inter-study

comparisons, the remaining seven studies had a larger sample size and were deemed statistically

significant after testing for internal reliability and validity (Bartolo et al., 2017; Demir et al.,

2019; Klein et al., 2015; Moyer et al., 2017; Okada et al., 2019; Rocca et al., 2016; Stam &

Fernandez, 2017; Waleed et al., 2017). Of the studies reviewed, two gathered participants from

multiple hospitals, while six studied patients from a single unit in one hospital (Bartolo et al.,

2017; Demir et al., 2019; Klein et al., 2015; Moyer et al., 2017; Okada et al., 2019; Rocca et al.,

2016; Stam & Fernandez, 2017; Waleed et al., 2017). Utilizing multiple hospitals to gather data

on participants allows for an increase in generalizability of the findings.

One study included patients with external ventricular drains (EVDs); researchers were

interested in determining the safety and feasibility of early mobility in patients at greater risk for

compromised cerebral spinal fluid drainage and catheter dislodgement (Moyer et al., 2017). The

results from this particular study on patients with EVDs decreases the transferability and internal
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validity of findings, due to the specificity of the patient demographic (Moyer et al., 2017).

However, this study does increase the generalizability for the TBI population. All studies

surveyed included patients admitted to the neurological ICU with primary neurologic injury and,

therefore, were related to the demographic of interest in the PICOT question.

Research Methods

Each study selected for this review explored the efficacy of an early mobility program in

TBI patients. Upon individual patient assessment of readiness for mobilization, most studies

began their research by assigning participants to one of two groups (Bartolo et al., 2017; Demir

et al., 2019; Klein et al., 2015; Moyer et al., 2017; Okada et al., 2019; Rocca et al., 2016; Waleed

et al., 2018). The two groups were (a) the intervention group which contained participants

enrolled in the early mobility program, and (b) the control group which included participants

who received standard bed rest protocol. The only study that did not utilize this approach was the

case study without a control group or means of comparison (Stam & Fernandez, 2017).

Although the studies utilized different approaches to early mobility, all applied

progressive mobilization strategies, including sitting the patient at the edge of the bed, standing,

performing side steps, PROM, and basic activities of daily living (ADLs; Bartolo et al., 2017;

Demir et al., 2019; Klein et al., 2015; Moyer et al., 2017; Okada et al., 2019; Rocca et al., 2016;

Stam & Fernandez, 2017; Waleed et al., 2018). To implement early mobility, some studies

utilized robotic devices such as mobile patient lifts and ICU bed features, while others used a

multidisciplinary team of physical therapists, occupational therapists, and the nursing staff to

assist and assure patient safety (Rocca et al., 2016; Stam & Fernandez, 2017). Most studies

began early mobility within one week of admission to the neurological ICU; however, Klein et

al. (2015) began mobility upon admission. The eight studies differed on length of treatment. For
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example, Demir et al. (2019) performed mobility protocols lasting 20 minutes per nursing shift,

whereas Klein et al. (2015) held rehabilitation for two to three hours daily. Length of

intervention ranged from a 13-day mobility program conducted by Klein et al. (2015) to a 12-

month program conducted by Moyer et al. (2017).

To establish an appropriate early mobility program, patients were assessed for readiness

based on previously mentioned inclusion and exclusion criteria upon admission to the

neurological ICU (Bartolo et al., 2017; Klein et al., 2015; Stam & Fernandez, 2017). Prior to

implementation of early mobility protocol, clinical neurological scales and level of mobility were

assessed to determine each patient’s neurological function (Bartolo et al., 2017; Demir et al.,

2019; Klein, et al., 2015; Moyer et al., 2017; Okada et al., 2019; Rocca et al., 2016; Stam &

Fernandez, 2017; Waleed et al., 2017). To measure improvement, the medical team performed

daily assessment of clinical scales (CGS, FIM, and ERBI), gait, tolerance of weight when

standing or sitting, flexion and extension of extremities, and ambulation with or without

assistance (Bartolo et al., 2017; Demir et al., 2019; Rocca et al., 2016; Stam & Fernandez, 2017;

Waleed et al., 2017). The data collected from all studies, focused on the effects of early mobility

on ICU length-of-stay and functional recovery, will help to address the PICOT question.

Research Findings

All studies showed significant findings that early mobility programs in ICU patients with

TBI led to either an increase in functional recovery, demonstrated through improved mobility

and neurological scales, or a decrease in ICU length-of-stay (Bartolo et al., 2017; Demir et al.,

2019; Klein et al., 2015; Moyer et al., 2017; Okada et al., 2019; Rocca et al., 2016; Waleed et al.,

2018). Klein et al. (2015) found that 21.2% of patients in the pre-intervention group who

received standard bed rest (control) were weight bearing (standing with or without assistance),
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while 42.7% of patients in the post-intervention group, who received early mobility

(intervention), were weight bearing. Moyer et al. (2017) found that patients have a 30% greater

chance of being discharged to their home or an acute rehabilitation center after a 12-month early

mobilization program than those who did not receive early mobilization. A systematic review

from 11 studies and 1,322 patients found that mobilization protocol, started within one week of

patient’s ICU admission, decreased patient’s length-of-stay in the ICU (Okada et al., 2019).

Functional Ambulation Classification, GCS, ERBI, and FIM were utilized to assess patient’s

neurological function over time (Bartolo et al., 2017; Demir et al., 2019; Stam & Fernandez,

2017). Results showed that patients who received early mobility versus bed rest or late mobility

(6-months post TBI) had a statistically significant improvement in neurological function.

Early mobilization for patients with neurological injury produces an increase in

functional recovery and a decrease in ICU length-of-stay compared to a standard protocol of rest,

therefore illuminating the PICOT question (Bartolo et al., 2017; Demir et al., 2019; Klein et al.,

2015; Moyer et al., 2017; Okada et al., 2019; Rocca et al., 2016; Stam & Fernandez, 2017;

Waleed et al., 2018).

Study Limitations and Future Implications

The major limitations across all studies included variations in exclusion/inclusion criteria

and timing/amount of mobilization, thus causing variations in internal validity (Bartolo et al.,

2017; Demir et al., 2019; Klein et al., 2015; Moyer et al., 2017; Okada et al., 2019; Rocca et al.,

2016; Stam & Fernandez, 2017; Waleed et al., 2018). While some of the studies were conducted

across multiple facilities, most took place solely on one floor of a single hospital, thus decreasing

the generalizability of the research findings (Klein et al., 2015; Moyer et al., 2017, Stam &

Fernandez, 2017). While most of the researchers utilized large sample sizes, Stam & Fernandez
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(2017) completed a case study on one patient, consequently decreasing transferability of results.

The studies that had a comparatively smaller sample size than the other articles (approximately

less than 70 patients), could potentially cause a decrease in significance of the study and increase

the margin of error (Demir et al., 2019; Moyer et al., 2017; Stam & Fernandez, 2017). Although

all of the studies failed to produce homogenous randomization of the participants within groups,

all participants were ICU patients with TBI, thereby decreasing performance biases (Bartolo et

al., 2017; Demir et al., 2019; Klein et al., 2015; Moyer et al., 2017; Okada et al., 2019; Rocca et

al., 2016; Stam & Fernandez, 2017; Waleed et al., 2018).

Another significant limitation across all studies was the lack in consistency of

intervention protocol (Bartolo et al., 2017; Demir et al., 2019; Klein et al., 2015; Moyer et al.,

2017; Okada et al., 2019; Rocca et al., 2016; Stam & Fernandez, 2017; Waleed et al., 2018).

While each study was able to support the PICOT question, the studies seemed to differ slightly in

the approach to early mobility, creating an uncertainty regarding the future implications and

transferability of findings.

Conclusion

The articles reviewed evaluated the effects of early mobility on ICU length of stay and

functional recovery, based on neurological scales and level of mobility, of ICU patients with

TBI. While exact interventions differ slightly, each article supports early mobilization as an

effective intervention to either reduce hospital length of stay, improve patient mobility, or

increase neurological function. The research findings provide provision for the proposed PICOT

question and clinical intervention of early mobility.

Clinical Implications
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This section of the paper will discuss clinical implications related to the PICOT question:

In critically ill patients with primary neurologic injuries, does early mobilization result in

reduced ICU length-of-stay and improved functional recovery, demonstrated in mobility level

and clinical neurological scales such as Glasgow Coma Scale (GCS), Early Rehabilitation

Barthel Index (ERBI), Functional Ambulation Classification (FAC), and Functional

Independence Measure (FIM), compared to standard protocol of bed rest? Previous research will

be utilized to design an early mobilization implementation plan for ICU patients with primary

neurologic injuries. The research articles used to create the implementation plan included those

classified as level II (Demir et al., 2019; Klein et al., 2015) and level III (Bartolo et al., 2017) on

the hierarchy of evidence by Dearholt and Dang (2017). The implementation plan, barriers to

implementation, ethical and cultural considerations, and gaps in the literature will be discussed.

Key Findings

Researchers found that early mobility programs among ICU patients with TBI led to

either an increase in functional recovery, demonstrated through improved mobility and

neurological scales, or a decrease in ICU length-of-stay (Bartolo et al., 2017; Demir et al., 2019;

Klein et al., 2015; Moyer et al., 2017; Okada et al., 2019; Rocca et al., 2016; Stam & Fernandez,

2017; Waleed et al., 2018). Studies showed that ICU patients who began a mobility protocol

within one week of admission had greater improvements in clinical neurological scales, such as

GCS, ERBI, and FIM, and level of mobility than those who began a mobility protocol later than

one week following admission (Bartolo et al., 2017). Improvement was shown through daily

assessment of neurological scales, gait, tolerance of weight when standing or sitting, flexion and

extension of extremities, and ambulation with or without assistance (Bartolo et al., 2017; Demir

et al., 2019; Rocca et al., 2016; Stam & Fernandez, 2017; Waleed et al., 2017). Research showed
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that utilization of a multidisciplinary team of physical therapists, occupational therapists, and the

nursing staff was a successful approach to early mobility (Rocca et al., 2016; Stam & Fernandez,

2017). Based on these key findings, an early mobility implementation plan for TBI patients was

created.

Implementation Plan

The early mobility implementation will utilize past research findings to create an

evidence-based practice (EBP) plan to increase functional recovery and decrease ICU length-of-

stay in TBI patients. Klein et al. (2015) used a progressive mobility protocol where patients

participated in a mobility activity at the start of each 12-hour nursing shift depending on the last

completed level of activity. The early mobility EBP will be modeled after Klein et al. (2015); as

patients complete a mobility milestone, they will progress to the next mobility level throughout

their length-of-stay in the ICU. Mobility will begin at the earliest level depending on patient

ability and assessment prior to beginning the program. Progression may begin with the patient

sitting at the edge of the bed, advancing to standing, performing side steps, PROM, and basic

activities of daily living (ADLs) with or without assistance (Bartolo et al., 2017; Klein et al.,

2015). A multidisciplinary approach utilizing occupational and physical therapists, nursing staff,

and speech pathology will collectively perform a total of two to three hours of daily treatment

lasting throughout patient length-of-stay (Demir et al., 2019). Daily treatment will include the

progressive mobility protocol, cognitive training, speech therapy, physiotherapy, mental health

support, and occupational therapy (Demir et al., 2019). Early mobility will begin on the day of

admission to the neurological ICU once patient readiness has been established. Participants will

include those who are fully conscious, able to communicate, not under the influence of sedatives

or muscle relaxants, at least 14 years of age, and able to maintain an oxygen saturation of at least
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95% (Waleed et al., 2017). The EBP plan will be compared to previous bed rest protocol or late

mobility, beginning one week after admission, for all TBI patients in the neurological ICU.

Modeled after Bartolo et al. (2017) and Demir et al. (2019), daily assessment of clinical

scales such as GCS, FIM, and ERBI will take place at the start of every 12-hour nursing shift to

assess functional recovery. Evaluation of mobility will be done through assessment of patient’s

gait, tolerance of weight when standing or sitting, flexion and extension of extremities, and

ambulation with or without assistance at the start of every 12-hours nursing shift (Bartolo et al.,

2017; Demir et al., 2019; Rocca et al., 2016; Stam & Fernandez, 2017; Waleed et al., 2017). This

early mobility EBP requires nurses to be involved as key stake holders to implement the specific

assessments and activities every 12-hour shift. However, in order to call nurses to be a change

agent, nurse leaders and management must come up with safe and feasible means to increase

nurse workload without adversely affecting the nurse or patient. The plan also calls occupational

therapists, physical therapists, and speech pathology to be key stakeholders since they will be

investing a large part of their time applying the early mobility protocols. As part of this plan,

nurses will need to be educated on proper body mechanics when mobilizing their patients.

Nurses will also need to be educated on how to properly assess patient readiness before

beginning the mobility protocol. Another consideration will be family education on expectations

and intensity of the early mobility program, and how their loved ones may respond.

Barriers to Implementation

Barriers to implementing the early mobility program could include issues involving time

management and staff education. Nurses are expected to perform daily assessments and basic

mobility protocols with their patients (Gwynedd Mercy University, 2020). However, the addition

of clinical neurological scales assessments, mobility assessments, and complex mobilization

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interventions would add significant time to the nurse’s full agendas. To ensure the additional

time spent on assessments safe and feasible, management could decrease the nurse patient ratio

to a strict one to one, or even provide an additional nurse for a single patient (Frazzitta et al.,

2015). Financial incentives, such as additional hourly compensation, could also be utilized for

nurses who are assigned a patient enrolled in the early mobility plan.

Another barrier involving nursing staff is the additional education that would be required

to adequately assess their patient’s readiness to begin early mobility (Bartolo et al., 2017; Klein

et al., 2015; Stam & Fernandez, 2017). If a patient is enrolled in a program that they may not

have been physiologically ready for, this could cause serious harm to the patient (Frazzitta et al.,

2015). Staff education may include additional expenses required to pay nurses to come into work

on a day off or could cause issues in time management.

Ethical, Cultural, and Spiritual Considerations

Implementing an early mobility program on neurological critical care patients requires

certain ethical, cultural, and spiritual considerations. The theory of autonomy requires

intentionality by the patient, understanding of the patient’s current condition and their options,

and the freedom of control from outside influences that may manipulate their decisiveness

(Beauchamp & Childress, 2013). The majority of patients assessed for early mobility will be

neurologically impaired (Common Classifications of TBI, n.d.). This could question whether the

patient is able to make a true autonomous decision if they impaired and possibly unable to

understand their condition and options fully (Beauchamp & Childress, 2013).

Another element to consider includes cultural and spiritual implications in healthcare. For

example, there are some cultures who may discourage weakness or think negatively of their

family member who denies potentially successful treatments due to possible increased pain and
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risk (Quality Interactions, 2020). Spirituality may also play a role with a patient denying an early

mobility program if they feel it is infringing on their God’s divine plan (O’Brien, 2011). These

things relate back to autonomy and how the patient providing consent may not have freedom

from outside influences manipulating their decision (Beauchamp & Childress, 2013). It is

important for the nursing staff to identify possible ethical, cultural, or spiritual considerations

when assessing patient readiness for the early mobility EBP program.

Gaps in the Literature and Future Research

While research findings support early mobility as a successful way to increase functional

recovery in TBI patients, there is limited research displaying a preferred length of mobility

program. The research shows major differences in discussing length of mobility programs, with

varying lengths of 13 days to 12 months (Klein et al., 2015; Moyer et al., 2017). Researchers

have also varied in the type of intervention performed for TBI patients. Further data is needed to

investigate variations in exact intervention, as well as length of mobility programs when

discussing the most successful approach to early mobility.

Conclusion

Research shows that early mobility among TBI patients in the ICU reduces hospital

length of stay, improves patient mobility, and increases neurological function. Key findings in

literature call for change in standard protocols among ICU patients diagnosed with primary

neurologic injuries. Through the use of past research and continuing to explore new EBP, nurses

along with management can represent the change agents needed to improve functional recovery

in TBI patients.
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Category Exemplary
90 – 100%
Transition Section Problem clearly identified.
Thesis statement and focus of
Maximum the paper clear to reader.
10 points Significance to nursing
discussed.
PICOT question included
Body – Plan for Appropriate findings from your
change literature review identified and
discussed.
Maximum Uses inference and reason to
30 points draw logical conclusions about
implications and
consequences.
Identifies a strategy and
potential problems.
Provides support for change or
innovation.
Transitions link sections and
paragraphs well.
Content vocabulary
appropriate, used well.
Evaluation outcome clearly
discussed and supported
Clear plan developed to
implement change in
practice.
Grading of Evidence, Barriers/Facilitators to change
Barriers/Facilitators identified and addressed,
to change, considered possible ethical
spiritual/cultural and implications, demonstrates
ethical insight and depth in
considerations discussion. Cultural and
20 points Spiritual Considerations
included.
Summary statement of grading
of evidence with citation.
Conclusion Clear, thorough summary.
Maximum Relevance to nursing clearly
15 points stated.
Recommendations clear and
supported.
No new content introduced
Assignment Addresses all required
Max. 5 points elements of assignment &
expands them.
Grammar & Spelling No grammar or spelling errors.
Max. 10 points
APA Format for Citations include all elements
Citations of APA formatting, according
examples in APA 7.01.
Max. 5 points
*Formatting Follows all APA formatting
guidelines; uses Word
Max.5 points functions appropriately,
introduction and conclusion
included
Meets Requirements
80 – 90%
Problem identified.
Thesis statement clear to
reader
Significance to nursing
identified.
PICOT question included
Literature review incorporated
adequately.
Draws logical conclusions.
Identifies a strategy and
potential problems.
Proposed change is
understandable and has
support in literature.
Evaluation outcomes
included.
Minor problems with
transition and order of
paragraphs or sections.
Content vocabulary generally
accurate.
Plan developed to
implement change in
practice, but not clear.
Minimal discussion of
possible barriers/facilitators,
minimal insight and/or depth.
Ethical, spiritual or cultural
considerations not all
included.
Summary statement of
grading of evidence with
citation.
Problem and findings
summarized.
Relevance to nursing
appropriate.
Recommendations
supported.
Addresses all required
elements of assignment.
1-2 minor errors per page.
No more than two minor
errors in APA style formatting
in all citations. Follows
examples in APA 7.01.
Follows all formatting
guidelines; minor problems
with Word functions.
Needs Improvement Points
<79%
Problem unclear.
Thesis statement unclear
or missing.
Significance to nursing
not addressed.
PICOT question not
included
Literature review not
incorporated adequately.
Findings unclear.
Strategies unclear or not
logical.
No support for proposed
changes.
No evaluation outcome or
evaluation outcome not
clearly supported.
Many or significant
problems with transition
and order of paragraphs
or sections.
Significant errors in
content vocabulary.
Plan unclear for change
in practice
No discussion of possible
barriers/facilitators, no
ethical considerations, no
spiritual/cultural
considerations, no
insight/depth
demonstrated.
No summary statement of
grading of evidence with
citation.
Summary inadequate.
Relevance to nursing
unclear or missing.
Recommendations
unclear or unconnected.
New content introduced
Fails to address all
required elements of
assignment
3 or more errors per
page.
More than two minor
errors or one significant
error in formatting in all
citations. Does not follow
examples in APA 7.01.
Formatting errors; page
length incorrect; poor use
of Word functions.
18
EARLY MOBILIZATION FOR BRAIN INJURY