Original Research

Early Mobilization in Critically Ill Patients: Patients

Mobilization Level Depends on Health Care Providers
Profession
Jaime Garzon-Serrano, MD, Cheryl Ryan, RN, Karen Waak, DPT,
Ronald Hirschberg, MD, Susan Tully, RN, Edward A. Bittner, MD, PhD,
Daniel W. Chipman, BS, RRT, Ulrich Schmidt, MD, PhD, Georgios Kasotakis, MD,
John Benjamin, MD, Ross Zafonte, DO, Matthias Eikermann, MD, PhD
Objective: To evaluate whether the level of mobilization achieved and the barriers for
progressing to the next mobilization level differ between nurses and physical therapists.
Design: Prospective, observational study.
Setting: Twenty-bed surgical intensive care unit (SICU) of the Massachusetts General
Hospital.
Participants: Sixty-three critically ill patients.
Methods: Physical therapists and nurses performed 179 mobilization therapies with 63
patients.
Outcome Measurement: Mobilization was defined as the process of enhancing mobility in the SICU, including bed mobility, edge of bed activities, transfers out of bed to a
chair, and gait training; the mobilization level was measured on the SICU optimal mobilization scale, a 5-point (0-4) numerical rating scale.
Results: Patients level of mobilization achieved by physical therapists was significantly higher
compared with that achieved by nurses (2.3 1.2 mean SD versus 1.2 1.2, respectively
P .0001). Different barriers for mobilization were identified by physical therapists and nurses:
hemodynamic instability (26% versus 12%, P .03) and renal replacement therapy (12%
versus 1%, P .03) were barriers rated higher by nurses, whereas neurologic impairment was
rated higher by physical therapists providers (18% versus 38%, P .002). No mobilizationassociated adverse events were observed in this study.
Conclusions: This study showed that physical therapists mobilize their critically ill
patients to higher levels compared with nurses. Nurse and physical therapists identify
different barriers for mobilization. Routine involvement of physical therapists in directing
mobilization treatment may promote early mobilization of critically ill patients.
PM R 2011;3:307-313

INTRODUCTION
Immobility due to prolonged bed rest in the intensive care unit (ICU) plays an important
role in the development of ICU-acquired weakness [1-3]. There is evidence to indicate that
skeletal muscle strength may decline by 1%-1.5% per day of strict bed rest [4] and 4%-5%
for each week of bed rest [5], which leads to a 10% reduction in postural muscle strength
after 1 week of complete bed rest [6]. Immobilization is associated with substantial
morbidity and may affect the rate of recovery and return to the patients former level of
function after critical illness and ICU treatment [2,7].
Investigators have even described the feasibility and potential benefits of mobilizing
patients in the ICU and those who are being mechanically ventilated [3,8-10]. Siebens et al
[11] show that an exercise program begun during hospitalization and continued afterward
results in improved function in instrumental activities of daily living 1 month after
hospitalization compared with that observed with usual care [11]. Prospective studies have
reported improved functional outcome with early mobilization of critically ill patients in a
PM&R
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Disclosure Key can be found on the Table of

Contents and at www.pmrjournal.org
This work was supported by funds from the
Massachusetts General Hospital Department
of Anesthesia, Critical Care and Pain Medicine, Boston, MA.
Submitted for publication July 30, 2010;
accepted December 30.
Author affiliations and disclosures are provided at the end of the article.

2011 by the American Academy of Physical Medicine and Rehabilitation

Vol. 3, 307-313, April 2011
DOI: 10.1016/j.pmrj.2010.12.022

307

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Garzon-Serrano et al

medical ICU [1,12]. Patients in the mobilization groups

treated with a defined activity regimen had more physical
therapy sessions, fewer days to first day out of bed, fewer
hospital days [1], better functional outcomes at hospital
discharge, a shorter duration of delirium, and more ventilator-free days compared with the usual-care group [12]. However, it is still unclear how to accomplish the optimal level of
mobilization in critically ill patients.
Mobilization is facilitated in the ICU by the physical
therapist (PT) and the registered nurse (RN) teams. It is not
known whether patients mobilized by PTs or RNs reach
different levels of mobility. Furthermore, the barriers to
mobilization are not well documented. We tested the hypothesis (primary) that physical therapists mobilize their
patients to higher levels than ICU RNs. We tested the secondary hypothesis that PTs and RNs defined different barriers for progressing to the next mobilization level. Mobilization was defined as the process of enhancing mobility in the
surgical ICU (SICU), including bed mobility, edge of bed
activities, transfers out of bed to a chair, and gait training; the
mobilization level was measured on the SICU optimal mobilization scale, a 5-point (0-4) numerical rating scale.

METHODS
The study was approved by the institutional review board of
the Massachusetts General Hospital, Boston, Massachusetts
(Partners Human Research Committee, 2008P001136).

Study Setting
The study was carried out in the SICU of the Massachusetts
General Hospital, a 900-bed teaching hospital that serves as a
community-based hospital, level-1 trauma center, and tertiary care referral center. The SICU is a 20-bed unit that
primarily admits vascular, thoracic, general surgery, and
complex trauma patients. The SICU is run with a transitional model that includes a medical director, a nurse manager, dedicated critical care RNs, PTs, registered respiratory
therapists, and a pharmacist. Patients are admitted to 1 of 2
teams (each consisting of an attending intensivist, a critical
care fellow, and residents) within the SICU. Admission to
each team occurs purely on the basis of bed availability, and
the 2 services do not differ with regard to the type of patients
and the medical or nursing coverage. All of the patients were
managed by using protocols for sepsis resuscitation, intravenous insulin for glycemic control, sedation with daily interruption, and liberation from mechanical ventilation. We
screened all of the patients admitted to our 20-bed SICU in
January 2010. Sixty-three patients were admitted to the SICU
during this study, and all of them were included in the final
analysis (Figure 1).
Before study initiation, it was postulated that there was
high variability among providers in efforts to mobilize pa-

EARLY MOBILIZATION IN CRITICALLY ILL PATIENTS

Figure 1. Patients flow through the study. During 1 month, 232

assessments of patients mobilization capacity were recorded
in the surgical intensive care unit (SICU) by 2 different groups of
health care providers: registered nurses (RN) and physical
therapists (PT). A total of 179 assessments were included for
analysis after exclusion of assessments with missing information.
Intent-to-treat analysis was done with data from 232 patients.

tients in the SICU. To study the issue, a SICU-based task

force was created to standardize assessment of the level of
patient mobilization. Guidelines were developed by consensus, with input from a number of involved personnel that
included RNs, PTs, a physiatrist, intensivists, respiratory
therapists, and surgeons. All care delivered during this study
was governed by existing hospital nursing and physical therapy policies and procedures, and no new experimental movement procedures were introduced.

Assessment of Mobilization Level

A 5-point (0-4) numerical scale was developed to assess the
mobilization level achieved by each patient. Phase 0 of activity refers to patients who were not able to be mobilized
because they had a contraindication (inability to accomplish
adequate arterial blood pressure or target oxygen saturation).
Phase 1 level of activity includes passive range of motion and
sitting in bed. For the upper extremities, passive range of
motion includes finger flexion and extension; wrist flexion,
extension, and ulnar and radial deviation; elbow flexion,
extension, supination, and pronation; shoulder flexion, abduction, and internal and external rotation. Shoulder extension was deferred because of positioning in bed. Lowerextremity passive range of motion included toe flexion and
extension; ankle dorsiflexion, plantar flexion, inversion, and

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eversion; knee flexion and extension; and hip flexion, abduction, adduction, and internal and external rotation. Hip extension was generally deferred because of positioning in bed.
Phase 2 activities include transferring the patient to a chair
via a mechanical lift and/or sitting on the side of the bed, and
were indicated if patients followed one step commands, and
performed volitional movement. Phase 3 activities characterize patients standing from a chair or side of bed. Phase 4
activities include patient ambulation.
The scale, validated with 100 patients in the SICU, revealed an excellent inter-rater reliability (r 0.96) among
nurses. The detailed results of the score validation (reliability,
and validity) study will be presented elsewhere.
To avoid any unwarranted limitation or withholding of
mobility interventions, we did not define specific cardiovascular or respiratory exclusion criteria for mobilizing patients.
If mobility was discontinued due to cardiovascular instability, the patients were re-evaluated for mobilization the following day. If the patients cardiovascular status was stable,
then the mobility was reinitiated. There were no absolute
limits with regard to the fraction of inspired oxygen (FiO2)
and positive end-expiratory pressure to withhold mobilization activities.

Data Collection
PT and RN providers independently assessed the level of
mobilization achievable for each patient and were blinded to
the activation level reported by other staff members. The RNs
performed mobilization therapy in all patients on a daily
basis, whereas the PTs performed mobilization therapy sessions for patients who had an ICU physicians order.
For all patients admitted to the SICU, the following data
were collected: age, gender, admission diagnosis, serum sodium, creatinine, albumin, arterial blood gases (FiO2, partial
pressure of oxygen [pO2], partial pressure of carbon dioxide
[pCO2], and pH), white blood cell count, and hemoglobin.
An Acute Physiology and Chronic Health Evaluation II
(APACHE II) score and a weighted index of comorbidity
score [13] were calculated for each patient.
During each mobility session, RNs and PTs assessed patients level of mobilization and identified barriers for further
mobilization (if any) by using the following dichotomous
categories: hemodynamic instability, neurologic impairment,
renal replacement therapy, orthopedic injuries, pain, bleeding, high ventilatory support, and do-not-mobilize orders.
Daily nursing acuity score (NAS, 0-6) reflects the time that
a nurse spent for patient care. This was recorded by the RN
and obtained from QuadraMed software (Reston, VA). Study
outcome data included the number of ventilator days. A
ventilator day was defined as any portion of a calendar day in
which the patient required a ventilator. Both measurements
were done to assess the patients disease severity.
We monitored any mobilization-associated adverse events
(AE) that occurred during and 30 minutes after treatment. An

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309

AE was defined as any unfavorable and unintended sign, symptom, or disease temporally associated with mobilization therapy.
Any AE that occurred during or 30 minutes after mobilization
therapy was recorded by the clinician as not related or as
unlikely, possibly, probably, or definitely related; the intensity
of the AE(s) was recorded as mild, moderate, or severe.

Statistical Analysis
We tested the primary hypotheses that PTs achieve a higher level
of patients mobilization (0-4 scale) compared with ICU RNs.
For sample-size estimation, we calculated that a sample size of
50 patients would provide power 80% to detect a significant
difference between providers ( 0.05). We subsequently
aimed at evaluating if the observed differences in mobilization
level among providers could be explained by differences in
patient characteristics. We compared, by independent sample
t-tests between the groups, age, gender, preadmission diagnosis,
duration of ICU stay before mobilization therapy, important
laboratory values taken on the study day (sodium, creatinine,
albumin, FiO2, pO2, pCO2, pH, WBC, Hb), weighted index of
comorbidity, APACHE II score, as well as treatment-related
variables (vasopressors, renal replacement therapy, mechanically ventilation, days on ventilator, nursing acuity score). We
included, in a mixed model analysis of variance (ANOVA), the
independent variables mobilization provider (dichotomous
variable) as well as 2 more variables that differed between the
provider groups in the univariate analysis, that is, duration of
ICU stay before mobilization therapy and nursing severity
score to test for an effect on the dependent variable mobilization level. The 2 test was applied for making post hoc comparisons among the different activity levels. We tested the secondary hypothesis that PTs and RNs define different barriers for
progressing toward the next mobilization level. Data analysis
was performed by using SPSS software (Version 11; SPSS Inc,
Chicago, IL).

RESULTS
A total of 232 measurements were conducted in 63 consecutive
patients (RN group, n 159 assessments; PT group,
n 73 assessments). After exclusion of 53 assessments due to
missing data points, 179 assessments were included in the final
analysis: 131 from RN and 48 from PT groups (Figure 1).
Measurements were conducted 6.5 8.5 days after patients
SICU admission, and were taken daily on 2.7 2.1 subsequent
days. Demographic characteristics (age, gender, body mass index, comorbidity index) did not differ between the RN and PT
groups (Table 1). The majority of the patients included in the
study were admitted to the SICU after major surgery (64% in the
RN group versus 55% in the PT group). Respiratory failure (18%
in the RN group versus 20% in the PT group) and hemodynamic
instability (8% in the RN group versus 10% in the PT group)
were the most frequent medical reasons that led to admission to

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Garzon-Serrano et al

EARLY MOBILIZATION IN CRITICALLY ILL PATIENTS

Table 1. Patient demographic information and baseline characteristics at surgical intensive care unit admission*

Age (y)
Gender
Na (mEq/L)
Creatinine (mg/dL)
Albumin (g/dL)
FiO2
pO2 (mm Hg)
pCO2 (mm Hg)
pH
WBC (mm3)
Hb (g/dL)
Weighted index of
comorbidity
APACHE II

RN

PT

P Value

58 15
33% women,
66% men
138 5
1.2 0.7
3.3 0.79
0.61 1.1
126 52
43 10
7.3 0.07
14.1 6.2
11.1 2.1
2.2 2.5

58 15
33% women,
66% men
139 7
1.1 0.7
2.8 0.63
0.43 0.16
104 39
44.9 4.9
7.3 0.05
15.5 6.6
9.9 1.6
1.9 2

.880
.392
.970
.281
.172
.684
.085
.223
.441
.356
.054
.668

98

12 12

.469

RN registered nurse; PT physical therapist; Na serum sodium; FiO2

fraction of inspired oxygen; pO2 partial pressure of oxygen; pCO2
partial pressure of carbon dioxide; WBC white blood cell count; Hb
hemoglobin; APACHE II Acute Physiology and Chronic Health Evaluation II.
*Data, other than gender, are mean standard deviation.

the SICU (Table 2). There also was no statistically significant

difference between the groups in morbidity index values or
APACHE II scores calculated at ICU admission. The nursing
severity score (P .001) was associated with patients level of
mobilization, but other variables that reflected the acuity of
patients disease were not (Table 3). Finally, there were no
differences in the proportions of patients in both groups in
treatment-related variables studied.
PTs compared with RNs examined the patients later during their ICU course (2.3 1.2 days versus 1.2 1.1 days
after admission, P .0001). The level of patients mobilization achieved by PTs was significantly higher (2.3 1.2
versus 1.2 1.2, P .0001) compared with that achieved by
RNs, a finding that remained significant even after correction
for the observed differences in timing of examination and
nursing severity score (P .04, mixed linear models
ANOVA) (Figure 2). Overall, 73% of RNs but only 37% of

Table 3. Surgical intensive care unit treatment-related variables that reflect the acuity of patients disease

Patients on vasopressors
Patients with arterial
catheters
Patients on renal
replacement therapy
Patients with central
access catheter
Mechanically ventilated
patients
Days on ventilator
Nursing acuity score (0-6)*

RN

PT

P Value

50%
77%

65%
85%

.190
.343

8%

15%

.298

52%

70%

.131

53%

75%

.067

7.4 12
5.1 0.5

10.6 15.5
5.5 0.5

.973
.0001

RN registered nurse; PT physical therapist. Days on ventilator and

nursing acuity score presented as mean SD.
*Recorded by nursing staff (QuadraMed software).

PTs (P .05) limited patients mobilization to within-bed

treatment (phase 1 activities). In turn, PTs mobilized their
patients to standing and ambulating levels in 38% of cases
versus 13% by RNs (P .05).

Barriers for Mobilization

Different barriers for progression to the next mobilization
level were identified by PT and RN providers; hemodynamic
instability (26% versus 12%, respectively; P .03) and renal
replacement therapy (12% versus 1%, respectively; P .03)
were barriers rated significantly higher by RNs, whereas
neurologic impairment was rated higher by PTs (18% versus
38%, respectively; P .002) (Figure 3).

Table 2. Admission diagnoses

Patients Diagnoses

RN

PT

P Value

Postoperative
Abdominal aortic aneurysm repair
Pancreatectomy
Esophagectomy
Tracheal resection
Sepsis
Small bowel obstruction
Pancreatitis
Respiratory failure
Cardiac arrest
Polytrauma
Hemodynamic instability

64%
16%
4%
4%
6%
8%
2%
4%
18%
6%
2%
8%

55%
10%
0%
10%
0%
5%
5%
5%
20%
15%
5%
10%

.332
.409
.507
.321
.358
.556
.493
.642
.545
.222
.493
.556

Data presented as percentage of patients.

Figure 2. Patients mobilization level accomplished by physical therapists (PT, open bars) and registered nurses (RN, filled
bars). PTs compared with nurses reported higher levels of
mobilization. PTs achieved activities above phase 2 in 38% of
cases versus 13% by RN. 0 No activity, 1 in bed only, 2
sitting in a chair, 3 standing, 4 ambulating. *P .05, P
.04, mixed linear models analysis of variance.

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311

Figure 3. Barriers for advanced mobilization reported by physical therapists (PT, open bars) and registered nurses (RN, filled bars).
Hemodynamic instability and renal replacement therapy were identified more frequently by RNs, whereas neurologic impairment
was the most important barrier identified by PTs. *P .05.

Intent-to-Treat Analysis
In accordance with the results of our final sample analysis,
our intent-to-treat analysis (n 232 measurements) showed
that, even before exclusion of missing data, PTs reported
significantly higher values of patients achieved mobilization
level (2.2 1.2 versus 1.3 1.2), and different barriers for
mobilization were identified by PT and RN providers. Hemodynamic instability (25% versus 15%, P .05) and renal
replacement therapy (13% versus 4%, P .04) were barriers
rated higher by RN providers, whereas neurologic impairment was rated higher by PTs (16% versus 37%, P .001).

AEs
There were no AEs such as accidental removal of a device during
mobilization. No deaths, near-deaths, or cardiopulmonary resuscitation occurred during mobilization in either group.

DISCUSSION
When compared with ICU RNs in this study, PTs achieved a
significantly higher level of patient mobilization. This finding
was independent of timing of examination and severity of the
patients disease. In addition, PT and RN providers define different barriers for progressing to the next mobilization level.
Whereas RNs were more concerned about hemodynamic and
respiratory variables that limited patients mobilization, PTs
reported patients neurologic function with a significantly
greater frequency as the main limitation to further mobilization.

Prolonged immobilization is harmful [2,14], and results of

recent studies have shown that early mobilization of critically ill
patients by a defined protocol improves a variety of outcome
variables, including ICU and hospital length of stay [1,15-17].
Whereas only AEs have been reported in relation to early immobilization [1,3,12,15,18], some clinicians are concerned about
safety, while keeping in mind that mobilization of critically ill
patients may increase the risk of hemodynamic or respiratory
instability and lead to unintended removal of the endotracheal
tube or vascular access devices [19-21]. In our study, no patient
was harmed during mobilization, and no complication or AE
occurred secondary to the mobilization.
The PTs reported a higher achieved mobilization level of
their patients compared with RNs, which might be explained by
time constraints and immediate prioritizations of care on the
nursing side and/or differences in the focus of their professional
responsibilities. RNs have more diverse responsibilities than
PTs, including but not limited to maintaining vital functions,
organizing and facilitating diagnostic studies, serving as an anchor for the team to facilitate communication with patients and
their families, or preparing documentation [22]. It is possible
that time constraints on the nursing side may in part explain our
finding that RNs achieved a lower level of patient mobilization
compared with PTs. In fact, the nursing severity score, which
reflected the hours spent with patient care, was a significant
predictor of the level of patients mobilization. The role of PTs in
the ICU setting includes regular neurologic assessment to enable
early detection of neurologic deficits, musculoskeletal assessment to ensure that fractures or soft-tissue injuries have not been

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Garzon-Serrano et al

overlooked, and to perform early detection of the onset of joint

stiffness or soft-tissue tightness or contracture formation. Accordingly, PTs, with their specific knowledge of neurologic and
musculoskeletal conditions [23] might be more focused on how
to advance individual patients with mobilization therapy.
There is increasing evidence that demonstrates the benefits of physical therapy in different medical scenarios. Physical therapy improves stair-climbing power and gait velocity
in elderly persons [24] and can even improve quality of life
after hip fracture [25]. Physical therapy has also been shown
to be effective in patients after a stroke, by producing statistically significant and clinically relevant improvements in
motor function that persist for at least 1 year [26]. A metaanalysis in stroke patients found that, over a 48 years of trials
that involved stroke rehabilitation, a prevailing theme with
respect to best outcomes was timing, or the onset of initiation
of early rehabilitation with physical therapy, as opposed to
intensity of therapies [27]. The benefits of different rehabilitation programs should be taken into account to improve and
standardize this intervention in critically ill patients [20].
However, AEs of excessive motor demand on cortical degeneration have been reported in animal studies [28], which
suggests that activity too early could put the rehabilitation
process at risk, if the animal data apply to humans.
Currently, in ICUs across the United States, 89% of PTs
require a physician consultation to initiate mobilization [29],
and we do not know if this approach helps to facilitate mobilization. Analysis of data suggests that patients transferred to an
ICU where early activity is a priority have an increased ability to
ambulate at discharge compared with those patients cared for in
the ICU without early activity [30]. It therefore might be important to focus on methods for promoting teamwork and collaboration among intensivists, PTs, and RNs, so that the specific
expertise of PTs in terms of mobilizing ICU patients can be
exploited for improved patient outcomes.
Barriers to early mobility can be patient related, provider
related, or cost related [31]. A recent observational study
identified several barriers to mobilization of patients; the
most frequently observed barriers were continuous renal
replacement therapy, intravenous sedation, and hemodynamic instability. In our study, RNs found renal replacement
therapy (26%) and hemodynamic instability (12%) as the
most important barrier to perform mobilization with critically ill patients, which is in accordance with the observations
of Schweickert et al [12].
We believe that strict exclusion criteria for early mobilization should be avoided whenever possible. By contrast, in
2008, the European Respiratory Society and the European
Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients published guidelines for mobilization of critically ill patients [32]. The complex algorithm
[32] may lead to the unnecessary exclusion of many critically
ill patients who probably would otherwise be able to safely
tolerate mobilization. As an example, per the algorithm,

EARLY MOBILIZATION IN CRITICALLY ILL PATIENTS

patients should not be mobilized if they have a PaO2/FiO2

300. If this single criterion had been used in our study, then
mobilization would not have been initiated for a majority of
our patients because the median PaO2/FiO2 was 200 in our
study. Accordingly, to avoid any unwarranted limitation or
withholding of mobility interventions, we did not define
specific cardiovascular or respiratory exclusion for mobilizing patients. To ensure cardiovascular stability, we asked the
health care provider to closely observe and maintain blood
pressure and heart rate in target range during mobilization,
considering the administration of vasopressors, volume, vasodilators, and pain medication as indicated. Dedicated
safety studies with a higher sample size are required to
evaluate the consequences of this approach in terms of safety.

Study Limitations
We did not perform a randomized controlled study, and we
need to consider that it is possible that the patients who
received mobilization therapy by PTs differed in terms of
severity of their disease from patients treated by RNs. We did
compare relevant variables that reflected the severity of the
patients disease between RN and PT groups; we did not find
a difference. Patients were treated by PTs significantly later
after SICU admission. However, analysis with mixed-model
ANOVA revealed that the health care providers profession
explained variance of patients mobilization level independent of timing of the mobilization therapy. The mean difference between groups of 0.9 points on the 4-point rating scale
is clinically meaningful, which represented a 48% difference
between groups. This effect is roughly the same as a 5-point
difference on the Likert scale.
In summary, our study results showed that PTs mobilize
their critically ill patients to higher levels compared with
nurses. RN and PTs providers identify different barriers for
mobilization. Analysis of our data suggests that routine involvement of PTs as part of a multidisciplinary team in
directing mobilization treatment is required to promote early
mobilization of critically ill patients.

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Footnotes Continued From Page 1.

D.W.C. Department of Respiratory Care, Massachusetts General Hospital, Boston, MA

Disclosure: nothing to disclose

J.G.-S. Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts

General Hospital, Boston, MA, and Harvard Medical School
Disclosure: nothing to disclose
C.R. Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts
General Hospital, Boston, MA, and Harvard Medical School; Department of Clinical
Nursing Services, Massachusetts General Hospital, Boston, MA
Disclosure: nothing to disclose
K.W. Department of Physical and Occupational Therapy, Massachusetts General
Hospital, Boston, MA
Disclosure: nothing to disclose
R.H. Department of Physical Medicine and Rehabilitation, Massachusetts General
Hospital, Boston, MA, and Harvard Medical School
Disclosure: nothing to disclose
S.T. Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts
General Hospital, Boston, MA, and Harvard Medical School; Department of Clinical
Nursing Services, Massachusetts General Hospital, Boston, MA
Disclosure: nothing to disclose
E.A.B. Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts
General Hospital, Boston, MA, and Harvard Medical School
Disclosure: nothing to disclose

U.S. Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts

General Hospital, Boston, MA, and Harvard Medical School
Disclosure: nothing to disclose
G.K. Division of Trauma and Surgical Critical Care, Massachusetts General Hospital,
Boston, MA
Disclosure: nothing to disclose
J.B. Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts
General Hospital, Boston, MA, and Harvard Medical School
Disclosure: nothing to disclose
R.Z. Department of Physical Medicine and Rehabilitation, Massachusetts General
Hospital, Boston, MA, and Harvard Medical School
Disclosure: 8B, NIH, NIDRR, DOD, Neurohealing/FDA
M.E. Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts
General Hospital, Boston, MA, and Harvard Medical School; Department of Respiratory
Care, Massachusetts General Hospital, Boston, MA; 55 Fruit St, Boston, MA 021142621;
Address correspondence to M.E.; e-mail: meikermann@partners.org
Disclosure: nothing to disclose