Early mobilisation is recommended to attenuate muscle weakness and improve outcomes for patients admitted to critical care. At present, there is no clear guidance on optimal dosage, with variations in the literature with regards to timing, frequency, intensity and type of activity [1].

The international, multicentre, randomised controlled Trial on Early Active Mobilisation (TEAM) investigated early, high-intensity mobilisation (highest mobilisation level for as long as possible until fatigued) to usual care mobilisation in 750 mechanically ventilated adults [2]. The primary outcome was days alive and out of hospital after 180 days. Secondary outcomes included mortality, ventilator-free days, and relevant patient-reported outcomes after 180 days.

Physiotherapy involvement was high in both groups, but participants in the intervention group were active significantly longer (12.0 min [95% CI 10.4 to 13.6]) and mobilised to higher levels earlier (for standing: −2 days [95% CI −3.4 to −0.6]) when compared to the control group. Interestingly, despite the increased activity levels seen, the highest mobilisation level achieved within critical care did not differ between groups, and there were no statistically significant differences between the two groups for any outcome.

However, as a note of caution, the intervention group experienced more adverse events. Whilst there were no falls, cardiac arrests, accidental extubations or line removals, there did appear to be a higher incidence of cardiac arrhythmias and oxygen desaturation, suggesting a certain degree of pathophysiological distress in response to the increased activity levels.

In conclusion, earlier and more intensive active mobilisation did not improve outcomes when compared to standard early mobilisation, but it was associated with more adverse events. When considering these results, it is important to place the trial’s methodology and findings within the context of other previous studies on early mobilisation.

In the TEAM trial, the control group mobilisation levels were similar to or higher than those seen in previous trials’ intervention groups [3] or standard care in many countries [4]. The strength of the TEAM trial thus lies within the high mobilisation standards of their control group that translates previous evidence of improved outcomes into practice. Therefore, the non-significant primary outcome should not hinder us from mobilising critically ill patients but rather challenge clinicians to achieve their standard of care.

Nevertheless, there seems to be a note of caution regarding how hard we can push our critically ill patients in the more acute phases of illness. Clinicians are recommended to weigh up the balance between intensity of physical activity and physiological reserve rather than always striving for progression or the highest mobility level possible [5].

STUDY STRENGTHS & LIMITATIONS

Strengths

Rigorous methodology, relevant and patient-centred outcomes (blinded assessors), reproducible intervention protocol with clear separation of physiotherapists delivering interventions, reporting of adverse events, prospective statistical analysis plan and a large, fully powered sample size.

Limitations:

• Highly selective cohort (7% of screened patients) that might exclude patients with the highest risk of muscle weakness
• Differences between the two interventions might have been insufficient to detect significant changes (i.e., number of days with physiotherapy assessments was only slightly higher in the intervention group: 0.14 [95% CI 0.12 to 0.16], both groups achieved a similar mobility level at ICU discharge, and some patients were not mobilised)
• Interventions are challenging to deliver: first, standard care has not yet been achieved in many countries; second, the intervention protocol is highly intensive for this patient group pushing patients until fatigued. More reporting about daily provided mobilisation is necessary to interpret the optimal dose adequately.

TAKE-HOME MESSAGES

The TEAM trial is the largest trial investigating early active mobilisation in critically ill patients. While there was no benefit in early, high-intensity active mobilisation, the intervention seemed to cause more arrhythmias and desaturations compared to standard care that achieved the same level of mobilisation in the ICU, though at a later time.

This implies that the optimal dose of early mobilisation might be a stepwise mobility protocol (from low to higher levels), with a variation on a daily basis to match any fluctuations in the patient’s condition and physiological reserve. Clinicians are recommended to consider patient fatigue and provide sufficient rest in-between sessions.

This article review was prepared and submitted by Sabrina Eggmann (Universitätsspital Bern, Switzerland) and David McWilliams, (University Hospitals Coventry and Warwickshire NHS Trust, UK) on behalf of the N&AHP and physiotherapy interest group.