Neurocritical Care

, Volume 30, Issue 2, pp 414–420 | Cite as

Early Progressive Mobilization of Patients with External Ventricular Drains: Safety and Feasibility

  • Rebekah A. YatacoEmail author
  • Scott M. Arnold
  • Suzanne M. Brown
  • W. David Freeman
  • C. Carmen Cononie
  • Michael G. Heckman
  • Luke W. Partridge
  • Craig M. Stucky
  • Laurie N. Mellon
  • Jennifer L. Birst
  • Kristien L. Daron
  • Martha H. Zapata-Cooper
  • Danton M. Schudlich
Original Article



Early mobilization of critically ill patients has been shown to improve functional outcomes. Neurosurgery patients with an external ventricular drain (EVD) due to increased intracranial pressure often remain on bed rest while EVD remains in place. The prevalence of mobilizing patients with EVD has not been described, and the literature regarding the safety and feasibility of mobilizing patients with EVDs is limited. The aim of our study was to describe the outcomes and adverse events of the first mobilization attempt in neurosurgery patients with EVD who participated in early functional mobilization with physical therapy or occupational therapy.


We performed a single-site, retrospective chart review of 153 patients who underwent placement of an EVD. Hemodynamically stable patients deemed appropriate for mobilization by physical or occupational therapy were included. Mobilization and activity details were recorded.


The most common principal diagnoses were subarachnoid hemorrhage (61.4%) and intracerebral hemorrhage (17.0%) requiring EVD for symptomatic hydrocephalus. A total of 117 patients were mobilized (76.5%), and the median time to first mobilization after EVD placement in this group of 117 patients was 38 h. Decreased level of consciousness was the most common reason for lack of mobilization. The highest level of mobility on the patient’s first attempt was ambulation (43.6%), followed by sitting on the side of the bed (30.8%), transferring to a bedside chair (17.1%), and standing up from the side of the bed (8.5%). No major safety events, such as EVD dislodgment, occurred in any patient. Transient adverse events with mobilization were infrequent at 6.9% and had no permanent neurological sequelae and were mostly headache, nausea, and transient diastolic blood pressure elevation.


Early progressive mobilization of neurosurgical intensive care unit patients with external ventricular drains appears safe and feasible.


Early mobility EVD External ventricular drain Neurointensive care unit Occupational therapy Physical therapy Ventriculostomy 


Author Contribution

RAY and SMA participated in study design and performed data collection. WDF, SMB and CMS participated in study design. CCC, LWP, JLB, KLD, MHZC and DMS performed data collection. LNM participated in manuscript preparation. MGH participated in study design and performed primary data analysis. All authors participated in manuscript preparation and read and approved the final manuscript.

Source of support

This study was funded by Mayo Clinic.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Klein K, Mulkey M, Bena JF, Albert NM. Clinical and psychological effects of early mobilization in patients treated in a neurologic ICU: a comparative study. Crit Care Med. 2015;43:865–73.CrossRefGoogle Scholar
  2. 2.
    Puthucheary ZA, Rawal J, McPhail M, et al. Acute skeletal muscle wasting in critical illness. JAMA. 2013;310:1591–600.CrossRefGoogle Scholar
  3. 3.
    Titsworth WL, Hester J, Correia T, et al. The effect of increased mobility on morbidity in the neurointensive care unit. J Neurosurg. 2012;116:1379–88.CrossRefGoogle Scholar
  4. 4.
    Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373:1874–82.CrossRefGoogle Scholar
  5. 5.
    Needham DM. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. JAMA. 2008;300:1685–90.CrossRefGoogle Scholar
  6. 6.
    Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36:2238–43.CrossRefGoogle Scholar
  7. 7.
    Engel HJ, Needham DM, Morris PE, Gropper MA. ICU early mobilization: from recommendation to implementation at three medical centers. Crit Care Med. 2013;41:S69–80.CrossRefGoogle Scholar
  8. 8.
    Hester JM, Guin PR, Danek GD, et al. The economic and clinical impact of sustained use of a progressive mobility program in a neuro-ICU. Crit Care Med. 2017;45:1037–44.CrossRefGoogle Scholar
  9. 9.
    Zink EK, Geocadin RG. Progressive mobility program in a neuro-ICU: What makes it different? Crit Care Med. 2017;45:1101–2.CrossRefGoogle Scholar
  10. 10.
    Avert Trial Collaboration group. Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. Lancet. 2015;386:46–55.CrossRefGoogle Scholar
  11. 11.
    Arnold SM, Dinkins M, Mooney LH, et al. Very early mobilization in stroke patients treated with intravenous recombinant tissue plasminogen activator. J Stroke Cerebrovasc Dis. 2015;24:1168–73.CrossRefGoogle Scholar
  12. 12.
    Cumming TB, Thrift AG, Collier JM, et al. Very early mobilization after stroke fast-tracks return to walking: further results from the phase II AVERT randomized controlled trial. Stroke. 2011;42:153–8.CrossRefGoogle Scholar
  13. 13.
    Hu MH, Hsu SS, Yip PK, Jeng JS, Wang YH. Early and intensive rehabilitation predicts good functional outcomes in patients admitted to the stroke intensive care unit. Disabil Rehabil. 2010;32:1251–9.CrossRefGoogle Scholar
  14. 14.
    Sorbello D, Dewey HM, Churilov L, et al. Very early mobilisation and complications in the first 3 months after stroke: further results from phase II of A Very Early Rehabilitation Trial (AVERT). Cerebrovasc Dis. 2009;28:378–83.CrossRefGoogle Scholar
  15. 15.
    Moyer M, Young B, Wilensky EM, et al. Implementation of an early mobility pathway in neurointensive care unit patients with external ventricular devices. J Neurosci Nurs. 2017;49:102–7.CrossRefGoogle Scholar
  16. 16.
    Hashem MD, Nelliot A, Needham DM. Early mobilization and rehabilitation in the ICU: moving back to the future. Respir Care. 2016;61:971–9.CrossRefGoogle Scholar
  17. 17.
    Bahouth MN, Power MC, Zink EK, et al. Safety and feasibility of a neuroscience critical care program to mobilize patients with primary intracerebral hemorrhage. Arch Phys Med Rehabil. 2018;99:1220–5. Scholar
  18. 18.
    Hale C, Wong K, Pennings A, et al. Practice patterns of Canadian physiotherapists mobilizing patients with external ventricular drains. Physiother Can. 2013;65:365–73.CrossRefGoogle Scholar
  19. 19.
    Muralidharan R. External ventricular drains: management and complications. Surg Neurol Int. 2015;6:S271–4.CrossRefGoogle Scholar
  20. 20.
    Dinglas VD, Parker AM, Reddy DR, et al. A quality improvement project sustainably decreased time to onset of active physical therapy intervention in patients with acute lung injury. Ann Am Thorac Soc. 2014;11:1230–8.CrossRefGoogle Scholar
  21. 21.
    Bakhru RN, Wiebe DJ, McWilliams DJ, Spuhler VJ, Schweickert WD. An environmental scan for early mobilization practices in U.S. ICUs. Crit Care Med. 2015;43:2360–9.CrossRefGoogle Scholar
  22. 22.
    Jolley SE, Regan-Baggs J, Dickson RP, Hough CL. Medical intensive care unit clinician attitudes and perceived barriers towards early mobilization of critically ill patients: a cross-sectional survey study. BMC Anesthesiol. 2014;14:84.CrossRefGoogle Scholar
  23. 23.
    Barber EA, Everard T, Holland AE, Tipping C, Bradley SJ, Hodgson CL. Barriers and facilitators to early mobilisation in intensive care: a qualitative study. Aust Crit Care. 2015;28:177–82.CrossRefGoogle Scholar
  24. 24.
    Harrold ME, Salisbury LG, Webb SA, Allison GT, on behalf of the Australia and Scotland ICU Physiotherapy Collaboration. Early mobilisation in intensive care units in Australia and Scotland: a prospective, observational cohort study examining mobilisation practises and barriers. Crit Care. 2015;19:336. Scholar
  25. 25.
    Mendez-Tellez PA, Nusr R, Feldman D, Needham DM. Early physical rehabilitation in the ICU: a review for the neurohospitalist. Neurohospitalist. 2012;2:96–105.CrossRefGoogle Scholar
  26. 26.
    Dubb R, Nydahl P, Hermes C, et al. Barriers and strategies for early mobilization of patients in intensive care units. Ann Am Thorac Soc. 2016;13:724–30.CrossRefGoogle Scholar
  27. 27.
    Shah SO, Kraft J, Ankam N, et al. Early ambulation in patients with external ventricular drains: results of a quality improvement project. J Intensive Care Med. 2018;33:370–4. Scholar
  28. 28.
    Gosselink R, Bott J, Johnson M, et al. Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med. 2008;34:1188–99.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society 2018

Authors and Affiliations

  • Rebekah A. Yataco
    • 1
    Email author
  • Scott M. Arnold
    • 1
  • Suzanne M. Brown
    • 2
  • W. David Freeman
    • 3
    • 4
    • 5
  • C. Carmen Cononie
    • 1
  • Michael G. Heckman
    • 6
  • Luke W. Partridge
    • 1
  • Craig M. Stucky
    • 1
  • Laurie N. Mellon
    • 1
  • Jennifer L. Birst
    • 1
  • Kristien L. Daron
    • 1
  • Martha H. Zapata-Cooper
    • 1
  • Danton M. Schudlich
    • 1
  1. 1.Department of Physical Medicine & RehabilitationMayo ClinicJacksonvilleUSA
  2. 2.Department of NursingMayo ClinicJacksonvilleUSA
  3. 3.Department of NeurologyMayo ClinicJacksonvilleUSA
  4. 4.Department of Critical CareMayo ClinicJacksonvilleUSA
  5. 5.Department of NeurosurgeryMayo ClinicJacksonvilleUSA
  6. 6.Division of Biomedical Statistics and InformaticsMayo ClinicRochesterUSA

Personalised recommendations