As the field of neurocritical care advances with new knowledge and technology leading to improved survival, promoting functional recovery and avoiding preventable adverse events due to immobility has become increasingly important. Mobility in the Neuroscience Intensive Care Unit (NSICU) has been shown to reduce the risk of pneumonia, pressure injuries, venous thrombotic events, delirium, ventilator days, and muscle deterioration (Jarvis et al., 2023; Kumar et al., 2020). Even passive mobility can foster a sense of recovery and well-being in a neuroscience patient who is unable to mobilize independently.  

Evidence-based early mobility programs promote interdisciplinary collaboration in multimodal optimization and task coordination. By integrating mobility goals into daily clinical rounds, the interdisciplinary team can discuss individualized patient goals and mobility plans. Although the “Standards for Neurologic Critical Care Units” acknowledge the benefits of physical, occupational, and speech therapists in the NeuroICU setting, implementation remains challenging. Despite the recommendation for 7-day coverage in rehabilitation therapies in Level I and II Neuro ICUs, many organizations face practical challenges related to staffing pressures, and a perceived increase in workload can be a barrier in early mobility programs. Advanced practice providers (APPs) have an opportunity to champion and drive protocol development that supports NeuroICU staff in safely mobilizing patients. Beyond order sets, which can be tricky to apply across all patient types, APPs have an opportunity to collaborate directly with bedside nurses and patients to achieve a tailored mobility plan. This APP collaboration can be a helpful way for APPs to strategize with staff to better predict workload needs while addressing patients' individual mobility needs. These interventions may be incorporated into programmatic quality improvement initiatives with enhanced support for monitoring outcomes and adherence.

While early mobility may be an essential component of improved outcomes, its implementation in the neurocritical care population poses challenges. Globally, guidelines vary, and standardized mobilization protocols are difficult to develop due to the heterogeneity and medical complexity of this patient population, as well as the need for individualized mobility dosing and timing of interventions (Nobles et al., 2024). When protocols are in place, they can be inconsistently implemented based upon many factors, such as staffing, time constraints, and higher priority cases or safety concerns, which often delay implementation of early mobilization in stable critically ill patients. As many hospitals face staffing shortages, this undoubtedly contributes to the immobility even in stable patients. Advanced Practice Providers can serve as mobility champions to ensure that the importance of functional recovery is not lost in the simultaneous pursuit of survival (Bruce & Forry, 2018; Moheet et al., 2018).

Programs and protocols that evaluate patients for early exercise and progressive mobility can be a powerful intervention for critically ill patients and are recognized as part of the ICU Liberation Bundle. Jarvis et al. ( 2023) implemented an early mobilization screening tool called Bedside Mobility Assessment Tool (BMAT) and protocol (> 24 hours after admission) in the NSICU at one academic center, reviewing a total of 198 patient charts (70 pre-implementation and 128 post-implementation) and found a reduction in admission to first out-of-bed activity from 3.24 to 2.01 days. The mean number of activities significantly increased from 6.13 to 8.25 (p = 0.002). There was a significant decrease in hospital length of stay from 19.8 days to 12.42 days (p = 0.006) . In another study of 1,117 NSICU patients, ICU and hospital length of stay, as well as psychological distress, showed significant improvements (p = 0.001) after initiating a mobilization protocol (Klein et al., 2018).

The collaboration of the interdisciplinary team, including APP and nurse-driven protocols, should promote the highest level of mobility by minimizing sedation, promoting early ventilator weaning, and daily screening to advance mobility. It is critical to involve bedside staff who are closest to the patient and spend the most time with them. In hemodynamically stable patients, nursing staff can facilitate further mobility in coordination with therapy staff while using Exclusion Criteria to identify critically ill patients who may be inappropriate for early mobilization. Guidelines recommend early mobility pathways for providers and nursing staff to ensure patient safety, streamline communication within interdisciplinary teams, and improve resource utilization. Typical medical exclusions include, but are not limited to the following:

Respiratory:

• FiO2 >60
• PEEP >10
• SpO2 <88
• Rate >35
• Arterial pH <7.25

Cardiovascular:

• MAP target unmet
• New diagnosis DVT/PE (24h)
• Acute MI (24h)
• Hypertensive crisis, acute phase of vasodilator infusions
• Unstable arrhythmia (24h)
• Bradycardia, requiring pacing/pharmacological treatment

CNS:

• Chemical paralysis
• RASS >+2
• ICP not in desired range/active management to bring ICP to goal
• Spinal precautions
• Uncontrolled seizures/status epilepticus
• Acute stroke (24h)

Surgical/other considerations:

• Uncontrolled/active bleeding
• Femoral sheaths/lines/catheters
• Unstable major fractures
• Open abdomen
• Comfort Care

Once early mobility has begun, it is vital to communicate daily assessments and planning for activity evaluation and progression. Interdisciplinary teams should document mobility level achieved at the end of the shift and develop tools to track progress and guide further mobility.

STROKE

While there is a variety of neurologic injuries and diseases seen in the NeuroICU, it is vital to remember that ischemic stroke is a disease of vascular insufficiency. The severity, location, and size of the infarction may be the best judge of whether a patient is a candidate for early mobility. Reperfusion status post-intervention needs to be considered as well, especially after intravenous thrombolysis or thrombectomy. Brain parenchymal and vascular neuroimaging may play an important role in determining candidacy for early mobility. Use of Transcranial Doppler (TCD) to assess vasomotor reactivity vs vasomotor exhaustion may provide clues to the competency of vascular tissue to provide optimal blood flow within ischemic territories. Other considerations include age and co-morbidities in addition to the neurologic process that is being treated in the NeuroICU.

The timing of mobility in this patient population has been influenced by the AVERT trial. The AVERT (Very Early Rehabilitation Trial) is the only source of high-quality evidence regarding very early mobility in stroke patients thus far. This trial spanned 56 acute stroke units across hospitals in the UK and Australia and recruited more than 2,000 patients. The intervention arm mobilized 4.8 hours earlier than the usual care arm with an additional three mobilization sessions per day. Fewer patients in the intervention arm had a favorable outcome at 3 months compared to the usual care arm (adjusted OR 0.73, 95% CI 0.59-0.90, p=0.004). These results cautioned clinicians to avoid very early high-dose mobility in stroke patients (Langhorne et al., 2017). The authors have followed up with an additional trial (AVERT-DOSE) in progress to determine optimal early mobility timing and dose (Bernhardt et al., 2023). Because of the findings in the AVERT trial, most centers restrict very early mobility within the first 24 hours of a stroke event, especially in those who are within 24 hours of post-acute stroke treatment. However, this should not apply to every patient and requires careful selection.

Knowing the mobility statistics for your unit can help APPs lead the charge and develop an action plan to increase mobility in stable patients along the continuum of care.  One group of APPs sought to evaluate mobility in stroke units and found that out of 366 patient observations in 4 U.S. Comprehensive Stroke Centers, patients were mobilized a median of 10 minutes in a 24-hour period. Forty-six percent (46%) were never mobilized. Independent predictors of immobility were the number of patients per nurse (p < 0.001), the presence of nursing assistants (p = 0.01), NIHSS score (p = 0.022), and stroke subtype (p = 0.034) (Swatzell et al., 2025).

Many of the mobility studies rely on manual documentation. Recognizing the need for external validation of mobilization activities involving NeuroICU patients unable to mobilize independently, some organizations have transitioned from the cumbersome manual documentation to using wearable technology. A new generation of patient-wearable sensors is now available in the United States. These are placed on the patient’s chest and can validate the degree of turns, upright activity, and the time spent in such activity. The sensor provides instant feedback to staff and the management teams via the electronic medical record (EMR) regarding compliance and outcomes specific to staff and the unit (Crotty et al., 2023; Nherera et al., 2021). Utilizing technology to decrease the documentation burden on staff is an important strategy. It should be considered for protocol or pathway development and allows for data collection, quality improvement, and strategies that promote mobility in stable patients.

SUMMARY

Mobility in the NeuroICU, when appropriately planned by clinicians with specialized expertise, promotes functional preservation and recovery across the continuum of care. Although most clinicians do not see the immediate outcomes of their mobility efforts in the NeuroICU, it is essential to know that these effects can lead to long-term functional improvements and promote independence. Clinicians who participate in the continuum of care for these patients should follow up with the NeuroICU staff to provide feedback on their efforts. This reinforces the patient's and family's potential for progressive recovery, as well as the staff's efforts and time.  While more information related to mobility dose and timing may be in progress, attention to this subject during rounds, handoffs, as well as quality improvement initiatives, can enhance successful outcomes for NeuroICU patients and provide a more consistent expectation of mobility across the continuum of care.