Abstract
Background Bed rest and immobility in patients on mechanical ventilation or in an intensive care unit (ICU) have detrimental effects. Studies in medical ICUs show that early mobilization is safe, does not increase costs, and can be associated with decreased ICU and hospital lengths of stay (LOS).
Objective The purpose of this study was to assess the effects of an early mobilization protocol on complication rates, ventilator days, and ICU and hospital LOS for patients admitted to a trauma and burn ICU (TBICU).
Design This was a retrospective cohort study of an interdisciplinary quality-improvement program.
Methods Pre– and post–early mobility program patient data from the trauma registry for 2,176 patients admitted to the TBICU between May 2008 and April 2010 were compared.
Results No adverse events were reported related to the early mobility program. After adjusting for age and injury severity, there was a decrease in airway, pulmonary, and vascular complications (including pneumonia and deep vein thrombosis) post–early mobility program. Ventilator days and TBICU and hospital lengths of stay were not significantly decreased.
Limitations Using a historical control group, there was no way to account for other changes in patient care that may have occurred between the 2 periods that could have affected patient outcomes. The dose of physical activity both before and after the early mobility program were not specifically assessed.
Conclusions Early mobilization of patients in a TBICU was safe and effective. Medical, nursing, and physical therapy staff, as well as hospital administrators, have embraced the new culture of early mobilization in the ICU.
Patients who are critically ill and admitted to an intensive care unit (ICU) have traditionally been placed on bed rest.1–3 Progression to sitting and standing often has been deferred in ICU populations until transfer to the floor, delaying mobility and increasing the risk for complications associated with immobility. This paradigm is being challenged with recent evidence demonstrating the safety and feasibility of mobilizing patients early in medical4–7 and surgical8,9 ICUs. Some of these studies showed that early mobilization of patients who were critically ill also resulted in a reduction in patient complications and ICU and hospital lengths of stay (LOS).2–8
Prolonged immobility, sedation, and mechanical ventilation during a critical illness have been associated with joint mobility restrictions, muscle weakness, critical illness neuromyopathies, pressure ulcers, deep vein thrombosis (DVT), prolonged mechanical ventilation, and psychological disturbances.3,10,11 Patients in a trauma and burns ICU (TBICU) are at similar risk for these complications,3,10,12 which may contribute to the body structure and function impairments, activity limitations, participation restrictions, and decreased quality of life seen in patients years after discharge from the TBICU.13–17 Yet, no previous studies have investigated the safety, feasibility, or effectiveness of early mobilization in patients who are critically ill and who have sustained traumatic or burn injuries.
Local Problem
The UAB Hospital is a 900-bed university hospital and an American College of Surgeons–verified level 1 trauma center. In 2004, a new emergency department and 28-bed TBICU were opened to handle increasing numbers of trauma visits each year. There were 54,654 visits to the emergency department in 2008,18 and approximately 1,000 of those patients were admitted to the TBICU. Even with additional space and staff, the volume of admissions created bottlenecks in the system, especially related to TBICU outflow.
Intended Improvement
To address capacity needs, hospital administration and the trauma and burns medical and nursing staff explored innovative ways to improve patient care and flow through the trauma system. Concurrently, members of the physical therapy department brought forward a proposal to initiate an early mobilization protocol for patients in the TBICU. Early discussions with trauma nursing and medical staffs indicated that this was the ideal opportunity to design and implement such a protocol for the TBICU. The early mobility program team included representatives from the medical, nursing and physical therapy staff.
Study Questions
Although early mobility in medical and surgical ICUs has been shown to be safe and feasible, the early mobility program team was unsure whether early mobilization would be safe in a trauma and burns population. Thus, the team's preliminary objective was to determine whether an early mobility program could be safely implemented in this population. Subsequent primary objectives were to assess the effects of an early mobility program on complication rates, ventilator days, and LOS in the TBICU and hospital.
Method
Ethical Issues
The University of Alabama at Birmingham (UAB) Investigational Review Board approved this initiative as a quality improvement project and waived the requirement for informed consent.
Setting
At UAB Hospital, patients who are critically ill and have injuries resulting from trauma or burns are admitted to the TBICU. Excluded from this population are patients with traumatic brain injuries, who are admitted to the Neurological ICU. A multidisciplinary team staffs the TBICU. Attending physicians, fellows, resident general and trauma surgeons, and trauma intensivists oversee the medical and surgical management of patients in the TBICU. Physician assistants facilitate patient management and communication among the disciplines. Registered nurses provide the majority of patient interventions on a 1:1 or 2:1 patient-to-nurse ratio. Nursing is responsible for titration of the sedation protocol and its interruption to perform scheduled neurological checks throughout the day, as well as patient positioning every 2 hours. Respiratory therapists are present on the unit at all times and manage the ventilator protocols, inhaled medications, and the majority of airway clearance interventions. Prior to implementation of the early mobility program, physical therapists were consulted as needed and followed no predetermined protocol. On average, patients were seen by physical therapists 2 to 3 days a week. Bed rest was the standard activity level ordered upon admission. This “usual care” for patients in the TBICU was similar to that reported by Morris et al in 20085 and Needham et al in 2010.3
The trauma and burns population differs significantly from those individuals admitted to medical ICUs. Most individuals with traumatic and burn injuries are independent at the community level prior to admission. Although comorbidities are present in individuals with traumatic and burn injuries, these comorbidities are not the primary reason for an individual's admission to the TBICU (eTable).19,20 Rather, a precipitating traumatic event, such as a motor vehicle accident, pedestrian injury, fall, blunt or penetrating injury, machinery injury, or burn, results in an individual's need for critical care. Respiratory failure in this population typically is not due to an acute infection or exacerbation of a chronic pulmonary condition, but rather due to chest trauma, smoke inhalation, or acute lung injury secondary to trauma. The mean Injury Severity Scale (ISS) score of patients admitted to the TBICU in 2009 to 2010 was 22.2 (SD=9.4–35), indicating that the majority of patients had injuries that were classified as severe to very severe.20
Planning the Intervention
A quality improvement framework of Plan-Do-Check-Act (PDCA) was used to develop and assess the early mobilization initiative in the TBICU.21,22 Peter Morris, MD, was contacted to clarify details of the early mobility program developed for patients in acute respiratory failure at Wake Forest Medical Center.5 Planning meetings were held between January 2009 and April 2009 with the acute care physical therapy manager, nurse manager, nurse educator, TBICU medical director, and trauma program director designated as program champions. Meeting discussions focused on: (1) development of an early mobility program tailored to the needs of the trauma and burn population, (2) contraindications to the protocol, (3) personnel and physical resources, (4) staff education, (5) sedation management, (6) barriers to implementation of the protocol, and (7) communication and coordination among team members.
Protocol development.
The early mobility program team reviewed and adapted the early mobility program described by Morris et al5 that progressed ICU patient mobility based on medical stability, cognitive abilities, and motor status. The program description, which includes interventions and progression criteria, is detailed in Table 1. The nursing standard of care included positioning of the patient every 2 hours and daily routine passive range of motion (PROM) as determined by the physical therapy staff. If more skilled range-of-motion activities were warranted, such as in patients with burns, a physical therapist performed this intervention. Active-assisted to active exercises were initiated in level 2, with progression to the use of weights and resistance bands in levels 3 and 4. Patient mobility was progressed by the physical therapist and integrated into the nursing plan of care.
Trauma and Burns Intensive Care Unit (TBICU) Early Mobility Program
Contraindications to the early mobility program.
As the safety of the early mobility program in a trauma and burns population had not been established before, the TBICU medical director identified specific contraindications to the initiation of early mobility program levels 2 and higher (Tab. 2). Cardiovascular, pulmonary and musculoskeletal instability formed the basis for the majority of the contraindications. In contrast to studies conducted in the medical ICU,5–7,23 we did not include medical diagnoses such as neurodegenerative diseases as contraindications to early mobility, as they are rarely seen in our population.
Contraindications to Trauma and Burns Intensive Care Unit Early Mobility Program Levels 3 and 4a
Personnel and physical resources.
An additional full-time physical therapist was required to support the early mobility program. Administrative approval for this position was obtained and interim staffing plans developed until this individual was hired. More bedside chairs were allocated to the TBICU to meet out-of-bed activities.
Staff education.
Nursing and physical therapy managers identified educational needs for both staffs. The physical therapy manager conducted overview sessions for all team members highlighting the need for and benefits of an early mobility program. To address PROM and common positioning and range-of-motion limitations seen in the TBICU population, physical therapists conducted 30-minute instructional sessions for all nursing staff, with resource materials available at each nursing station. Physical therapists underwent more intensive training in respiratory care procedures, mechanical ventilation management, emergency procedures related to unintentional extubation, and sedation and analgesia management.
Sedation management.
The sedation protocol did not change for the early mobility program. However, patients in levels 2 to 4 received more frequent sedation interruptions to enable them to actively participate in the early mobility program.
Barriers.
The early mobility program team members reported barriers to implementation similar to those cited in other studies5,11,24,25: time and a fear that more aggressive mobility activities would result in increased risk of cardiac and pulmonary complications. To address the safety concerns, outcomes associated with previous early mobilization studies were reviewed and reinforced with staff. During the first several weeks, team members underestimated the time that care coordination required while overestimating time needed for the performance of actual activities. As the teams reached higher levels of performance, they no longer viewed time as a barrier.
Communication and collaboration.
Timely and efficient communication among team members was a critical component to ensuring the initiative's success. The physical therapist rounded with the nurse manager each morning to discuss changes in patients' status, including planned procedures for the day. After conference, the medical staff shared updated patient reports with the physical therapist and clarified weight-bearing and other precautions. Collaborative team work ensured that mobility was prioritized while not interfering with other care.
Physical therapy and nursing staff documented completed activities on a bedside flow sheet (Appendix 1). As patient activity levels changed, the physical therapist indicated this on the form. When applicable, the physical therapist also posted at the bedside a PROM/Mobility Precautions form that described precautions to PROM for the nursing staff (Appendix 2). Conditions that limited performance of PROM included those that required spine or limb immobilization to prevent further injury or promoted healing, such as skin grafting.
Planning the Study of the Intervention
Effectiveness of the early mobility program was assessed using measures that considered patient safety and outcomes. The hypotheses tested were that early mobilization of patients in the TBICU would be safe and feasible and result in fewer complications, shorter TBICU and hospital LOS, and no increase in adverse events during a mobility session. Results from the pilot program at 4 months revealed a significant decrease in ventilator-acquired pneumonia and venous thromboembolism.26 The team agreed to continue the early mobility program for an additional 8 months so that further data collection and analyses could be conducted to evaluate outcomes and processes. The selected study design was a retrospective cohort study. Data were collected through established hospital electronic systems that included risk management systems for documentation of incidents and adverse events, the trauma registry for demographic, injury, and clinical characteristics of the participants, and the billing system for confirmation of increased physical therapy intervention in the TBICU.
Methods of Evaluation
Clinical and demographic data were collected for patients admitted to the UAB Hospital TBICU from May 2008 through April 2010 from the UAB trauma registry. Registry data are entered by trained registrars, with data collected from medical charts, and are compared with documentation in the electronic record to verify findings. Additionally, interrater reliability analyses are performed among sampled records to ensure data are entered correctly among registrars. Those patients admitted from May 2008 through April 2009 were categorized as admitted prior to early mobilization implementation (pre–early mobility program), and those admitted from May 2009 through April 2010 were categorized as admitted after early mobilization implementation (post–early mobility program). For each patient, information was collected on demographic, injury, and clinical characteristics. In addition, common comorbidities that may have affected the ability of patients to participate in the rehabilitation program were documented.
A primary outcome of interest was safety as related to nosocomial complications and adverse events. Each complication was reviewed, and placed into one of the following categories: airway, acute respiratory distress syndrome, cardiovascular, hematologic, musculoskeletal/integumentary, neurologic, psychiatric, pulmonary excluding pneumonia, pneumonia, renal/genitourinary, sepsis, vascular, DVT, and pressure ulcer. For each patient, the occurrence of a complication was counted only once (ie, only the first occurrence of the complication was considered). Adverse events related to safety during mobility sessions were categorized as: involuntary or self-extubation, decannulation (vascular device), fall, cardiac event (eg, arrest, new onset of ventricular tachycardia or fibrillation, hypotension, severe hypertension), or respiratory event (eg, distress, failure). Billing records for two 3-month periods in 2008 and 2009 (August–October) were used as a surrogate marker for “dose of mobility.”
Data Analysis
Demographic, injury, and clinical characteristics were compared between the early mobility program's implementation groups using the chi-square test and the t test for categorical and continuous variables, respectively. Additionally, a chi-square test was used to determine whether the early mobility program's implementation groups differed by comorbidity status. A Cox proportional hazards model was used to estimate risk ratios (RRs) and 95% confidence intervals (CIs) for the association between early mobility program implementation and complication occurrence. Models were adjusted for age and injury severity, as measured by the ISS. For each model, time at risk was defined as the time to the adverse event (eg, pneumonia) or hospital discharge, whichever occurred first. To meet the assumptions of a Cox model (ie, hazards are proportional across categories of a certain variable), age and ISS were categorized. For all analyses, SAS version 9.2 (SAS Institute Inc, Cary, North Carolina) was utilized. Descriptive data were obtained for billable physical therapy units charged.
Results
Institutional Outcomes
Delivery of patient care in the TBICU was transformed from a multidisciplinary approach in which each discipline operated in parallel to an interdisciplinary approach where collaboration, communication, and problem solving occurred beyond the confines of individual disciplines. Nurses, physical therapists, respiratory therapists, and physicians worked together to prioritize patients' mobility needs. The early mobility program teams assumed accountability for their performance and developed self-management skills that promoted ownership of goals and a shared decision-making process.
Patient Outcomes
From May 2008 through April 2010, 2,176 patients were admitted to the TBICU, 1,044 of whom were admitted prior to early mobility program implementation and 1,132 were admitted after early mobility program implementation (Tab. 3). Those admitted before early mobility program implementation were younger (P<.01), were more likely to be male (P=.02), and had higher ISS scores (23.6 versus 22.2, P=.01) (Tab. 3). Regarding comorbidities, those admitted to the ICU prior to early mobility program implementation were less likely to have arthritis (P<.001), cardiovascular disorders (P=.01), diabetes (P<.001), neurologic disorders (P=.03), sleep apnea (P =.04), or pulmonary disorders (P=.03; Tab. 3).
Demographic, Injury, and Comorbidity Characteristics of Patients Admitted to an Intensive Care Unit Prior to and After Implementation of an Early Mobility Program (EMP)a
The overall hospital LOS was significantly shorter, by 2.4 days, in the post–early mobility program group (P=.02; Tab. 4). When adjusted for the ISS score, hospital stay length remained 1.5 days shorter but was statistically insignificant (data not shown). There were no differences in TBICU days, mechanical ventilation days, mortality, and discharge disposition between the 2 groups.
Comparison of Hospitalization and Disposition Characteristics and Complication Rates of Patients Admitted to an Intensive Care Unit (ICU) Prior to and After Implementation of a Trauma and Burns Intensive Care Unit Early Mobility Program (EMP)
Based on significant differences in complication rates between groups (Tab. 4), we adjusted for age and injury severity and calculated RR values (Tab. 5). After early mobility program implementation, patients were less likely to have pneumonia (RR=0.79, 95% CI=0.66–0.93), DVT (RR=0.67, 95% CI=0.50–0.90), airway complications (RR=0.52, 95% CI=0.35–0.76), pulmonary complications (RR=0.84, 95% CI=0.74–0.95), or vascular complications (RR=0.58, 95% CI=0.45–0.75).
Crude and Adjusteda Risk Ratios (RRs)b and Associated 95% Confidence Intervals (95% CIs) for the Association Between Hospital Complications and Implementation of an Early Mobility Program (EMP) Among Patients in a Trauma and Burns Intensive Care Unit
Although not significantly different, a trend toward an increased relative risk for cardiovascular complications was observed for the post–early mobility program group (RR=1.26, 95% CI=0.99–1.59) (Tab. 5). Due to this trend for increased cardiovascular complication risk, further analyses were performed. Models were created for each individual type of cardiovascular complication. A notable, but statistically insignificant, risk was observed for pericardial effusion or tamponade (RR=4.11, 95% CI=0.88–19.09). Nonspecified cardiovascular complications (RR=1.81, 95% CI=1.16–2.83) were statistically significantly increased in the early mobility program group. Dysrhythmia, unexpected cardiac arrest, cardiogenic shock, myocardial infarction, and shock rates remained unchanged.
No adverse events were reported in the risk management system for patients during a mobility event in either time period. Billable units increased 100% in the post–early mobility program period, with an average of 21.1 units charged per day (Tab. 6). Physical therapy billable units per visit increased from 1.5 to 2.2.
Comparison of Physical Therapy Utilization for Patients in a Trauma and Burns Intensive Care Unit Admitted Prior to and After Implementation of an Early Mobility Program (EMP)a
Discussion
Summary
This quality improvement initiative demonstrated that early mobilization of patients admitted to a TBICU was safe and effective. Neither acute adverse events nor increased complications associated with early mobility were reported. Our results indicate that during the early mobility program period, patients in the TBICU significantly reduced airway, pulmonary, and vascular complications. Hospital LOS was not found to be different when adjusted for injury severity and age, as were days of ventilator support and TBICU LOS.
Interpretation and Relation to Other Evidence
Early mobility of patients in critical care settings has gained momentum in the literature over the past few years, with at least 29 articles published on the topic since January 2007.1–12,23–25,27–39 Of these publications, there are at least 6 quality intervention studies assessing the role of exercise or mobility for patients in an ICU setting.3–5,7,8,31 For most of our comparisons, we will focus on the 3 studies most similar to ours, although the setting for these studies was a medical ICU. Our early mobility interventions were modeled after that of Morris et al5 and were very similar to those of the more recent studies of Schweickert et al7 and Needham et al.3
Early mobilization of patients who are critically ill is safe as measured by mortality rates, adverse events, and discontinuation in therapy sessions due to patient response to activity. In our study, mortality did not significantly change with implementation of the early mobility program. Both Schweikert et al7 and Needham et al3 also reported no changes in mortality. As defined by our study protocol, no adverse events occurred during early mobilization. Schweikert et al7 reported one case in which decannulation of the radial artery catheter occurred. In other studies, temporary or permanent session disruptions in therapy were considered to be adverse events and were reported to occur in 4% and 16% of sessions.6,7
We did not have any significant increase in iatrogenic complications in the early mobility group. To the contrary, we found a decrease in many complications. Based on our outcomes, we found that ambulation with endotracheal intubation was a safe intervention. Airway complications related to reintubation were reduced 50% in the post–early mobility program group, and no unplanned extubation occurred during any mobility event. A reduction in pneumonia and other pulmonary complications (eg, adult respiratory distress syndrome, pneumothorax, pulmonary embolism) seen after the early mobility program was likely due to improved ventilation/perfusion matching, lung compliance, and mucociliary clearance and a reduction in the work of breathing in upright postures.40 In retrospect, given the significant reduction in airway, pulmonary, and pneumonia complications found in this study, perhaps daily fiberoptic bronchoscopy did not need to be an absolute contraindication to mobility. The literature suggests that early mobility and airway clearance techniques may be effective as interventions for smoke inhalation.41,42
Because hospitalization, immobility, and especially orthopedic and spinal trauma are risk factors for DVT,43 the reduced incidence of DVT in the early-mobility group could be explained by early active lower-extremity exercises with physical therapy and frequent out-of-bed mobility episodes.44 As proximal DVTs are prone to embolization, the reduction in DVT and other vascular complications in the present study also may explain the decrease in nonpneumonia pulmonary complications, which include pulmonary embolism. Previous studies examining DVT and pulmonary embolism incidence have not shown such a decrease.5,8
On initial analysis, only cardiovascular complications increased in the post–early mobility program group. Although they were statistically insignificant after adjusting for age and injury severity, we decided that further exploration was warranted. Several factors may have contributed to the noted increase in cardiovascular complications. Although the incidence of cardiovascular comorbidities was higher in the early mobilization group, both groups experienced similar rates of dysrhythmias, unexpected cardiac arrest, congestive heart failure, cardiovascular shock, and myocardial infarction, which conceivably could be related to mobility complications in an ICU population. Pericardial effusion, tamponade, and unspecified cardiovascular complications were higher in the early mobility program group; however, no evidence supports early mobility as a likely cause of these complications. Blunt trauma to the chest, surgical trauma, or infections are more likely explanations in our population.45
Although hospital LOS adjusted for injury severity was reduced by 1.5 days in the post–early mobility program group, this finding was statistically insignificant. Morris et al5 found a decrease in overall hospital LOS from 14.5 days to 11.2 days (P=.006) when adjusted for body mass index, Acute Physiology and Chronic Health Evaluation II scores, and vasopressors. Unlike other studies,3,5 our study did not demonstrate that ICU LOS was changed as a result of early mobilization. Although the factors that may have contributed to an overall shorter LOS are not clear, we postulate that patients in the post–early mobility program group were transferred to the floor having experienced fewer complications, thus decreasing the extent of further rehabilitation services and other required care prior to discharge. Morris et al5 suggested that factors such as care standardization, a multidisciplinary approach to mobility, earlier initiation of physical therapy, and a reduction in missed visits may contribute to decreased LOS.
It is difficult to accurately assess how much “mobility” or physical activity patients received after implementation of the early mobility program. Although the TBICU census and number of days physical therapy staff provided care in the TBICU during this 92-day period was not different, there was a 100% increase in total physical therapy billable units, as well as an increase in the units of physical therapy provided per day of service and per visit. This measure of dosage indicates a substantial increase in both frequency and duration of interventions provided by physical therapy staff, but it fails to capture the patients' mobility throughout the day with nursing and respiratory therapy, as well as on their own.
Early mobilization protocols are possible due to a deliberate effort to involve all stakeholders in the planning process and a shift from multidisciplinary to interdisciplinary patient care. From the outset, the quality improvement leadership group empowered bedside caregivers to work collaboratively and develop ownership of the early mobility program.30 The concept of flexibility evolved from that defined as a willingness to change individual schedules to the willingness to compromise and develop new skill sets outside those traditionally assumed by a profession.30 Long-term outcomes were linked to team processes, enabling team members to recognize that individual effort alone was not sufficient in optimizing patient outcomes. Bailey et al30 suggested that collaboration is as important as or more important than individual effort when teams must deliver complex care. Thomsen and colleagues' study demonstrated that an intensive care environment focused on early mobility by a dedicated and trained team was the single strongest predictor of ambulation compared with other medical ICUs in the facility.29
As a result of our study's findings, the acute physical therapy department has justified establishing 2 additional full-time physical therapist positions to support the program in the TBICU and establishing one in the surgical ICU. Development of a protocol for nurses and physical therapists has further integrated early mobilization into the routine care of patients in the TBICU despite staff turnover. As an ongoing component of quality improvement, we plan to conduct periodic chart audits to assess program fidelity and provide ongoing educational sessions for new employees.
Limitations
The ability to generalize findings from this study is constrained by the retrospective study design. A second limitation to our study is that we were unable to confirm the mobility “dose” or to specifically quantify the physical activity levels of individual patients in our early mobility program. Additional variables related to physical therapy interventions, such as the number of visits provided per protocol level, were difficult to measure, as the patients frequently moved between levels and adequate staff were not available to conduct large-scale chart reviews. Femoral lines were listed as one of our contraindications to the early mobility program, but recent evidence suggests that patients with these lines may be safely mobilized.38
Conclusions
Early mobility in patients who are critically ill and have traumatic and burn injuries is safe and feasible and resulted in decreased pneumonia and DVT, as well as airway, pulmonary, and vascular complications. Medical, nursing, and physical therapy staff, as well as hospital administrators, have embraced the new culture of early mobilization in the TBICU.
Future multicenter randomized controlled trials of early mobilization in the ICU to assess protocols and determine physical activity dosage are needed to provide conclusive evidence of early mobilization benefits, as well as to help guide mobility interventions. Studies to determine long-term outcomes associated with implementation of early mobility programs may demonstrate additional benefits to critically ill populations and reductions in cost to the institution.
Appendix 1.
Trauma and Burns Intensive Care Unit Mobility Team Flow Chart (Not Part of Medical Record)a
a PROM=passive range of motion, PT=physical therapy.
Appendix 2.
PROM/Mobility Precautions Forma
a PROM=passive range of motion, L=left, R=right, WB=weight-bearing status.
Footnotes
All authors provided concept/idea/research design. Dr Clark, Dr Lowman, and Dr Griffin provided writing. Dr Clark, Dr Lowman, Dr Griffin, and Ms Matthews provided data collection. Dr Lowman and Dr Griffin provided data analysis. Ms Matthews provided facilities/equipment. Dr Reiff provided study participants and consultation (including review of manuscript before submission). The authors thank Donald H. Lein Jr, PT, PhD, Kelly Sheils, BSN, Twanda Coates, BSN, Tammy Herdeman, members of the TBICU Trauma Staff, and the Trauma Registry Staff for assistance.
Pilot data were presented at the Acute Care Section of the Combined Sections Meeting of the American Physical Therapy Association; February 17–20, 2010; San Diego, California.
This publication was made possible by the UAB Center for Clinical and Translational Science Grant UL1TR000165 from the National Center for Advancing Translational Sciences (NCATS) and National Center for Research Resources (NCRR) component of the National Institutes of Health (NIH). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.
- Received November 16, 2011.
- Accepted August 2, 2012.
- © 2013 American Physical Therapy Association
References
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