Patients with neurological diseases can also have disabilities that result in transient or permanent loss of functioning. Motor and sensory impairments, cognition decline, as well as differences in language or perception, mean many patients require assistance with the activities of daily living (1). In a hospital environment, this population are prone to bed rest and generally have limited mobility levels (2). For example, Bernhardt et al. (3) outline that patients rest in bed more than 50% of the time during a hospital stay. Early Mobility (EM) has been suggested as a powerful intervention that promotes a higher level of mobility, reduces the length of hospital stay, and enables them to achieve better functioning after discharge, as it allows independence during hospitalization (4, 5). Nurses and physiotherapists are the main professionals in the rehabilitation team who assess patients' motor activities and encourage mobility during a hospital stay (6).

Perme and Chandrashekar (7) defined EM in intensive care units as a mobility program that includes educational efforts, positioning care, mobility training in bed, and walking activities. They initiate EM when a patient has minimal ability to engage in therapy and a stable clinical status. In the same way, Drolet et al. (8) have constructed an EM protocol that progresses through the patient's mobility level, increasing the percentage of patients ambulating during the first 72 h of hospital stay.

Considering a stroke population, the timing for initiating EM is crucial for the effectiveness of this intervention (4). Bernhardt et al. (9) outline the timing of important biological processes in the cerebral tissue after stroke with implications for rehabilitation time. They propose a timeline of biological events and recovery potential since the hyperacute phase (0–24 h after stroke), acute (24 h−7 days), early subacute (7 days−3 months), late subacute (3–6 months) until the chronic phase after stroke (>6 months). EM trials usually investigate the repercussion of this approach in the first week after stroke, contemplating the recovery potential of brain plasticity.

EM in stroke units usually includes out-of-bed activities that can be initiated between 24 and 72 h. In this context, EM is related to the reduction of length of hospital stay, and independence in walking activity, with no occurrence of adverse events (10, 11). Otherwise, EM can also be initiated after the first 24 h of stoke (known as Very Early Mobilization–VEM) depending on the duration, frequency, and intensity of exercises, VEM can reduce the odds of favorable outcomes 90 days post stroke, as seen in AVERT phase III (12). A high-dose of very early mobilization within 24 h of stroke onset is not recommended by the AHA Stroke Guidelines of 2016 and 2019 (13, 14).

Since then, numerous trials have been investigating the effects of EM and VEM in stroke patients. Two recent systematic reviews by Langhorne et al. (15) and Rethnan et al. (16) investigated large trials of VEM and EM since 2008. The authors recommend that the commencement of mobilization should only be considered 24 h post-stroke, but the determination of the optimal dose of mobilization, as well as the identification of responders and non-responders to treatment remains unclear.

The acute phase of a neurological condition during hospitalization is timely to estimate the functional condition of these patients (17). The strength of muscles as hip extensors and trunk stabilizers (TWIST algorithm) seen in the MRC score can predict the need for assistance during walking 12 weeks post cerebral ischemia (17). The strength of hip abductors, ankle dorsiflexors, and trunk control (HAAD score) can predict good functional prognostics 90 days after hospital discharge (18). All of these groups of muscles usually are stimulated in activities performed in EM protocols.

EM protocols are generally composed of activities such as sitting out of bed, standing, and walking (9). In AVERT phase II (10), out-of-bed activities are stimulated in the hyperacute stroke phase and demonstrate the good feasibility and effectiveness of this intervention. AMOBES trial (11) compared passive mobilization and out-of-bed activities with resistive exercises in the trunk and limbs plus intensive task-oriented training commencing <72 h from a stroke. The authors found no change in the motor domain of the Fugl–Meyer score between both interventions.

Most of the motor activities presented in EM protocols can be measured by physiotherapists across diverse functional scales such as Physical Function in Intensive Care Test–scored (PFIT -s) (19), Chelsea Critical Care Physiotherapy Assessment Tool (CPAx) (20), Functional Status Score for the Intensive Care Unit (FSS ICU) (21), Intensive Care Unit Mobility scale (IMS ICU mobility scale) (22), John Hopkins Highest Level of Mobility (JH-HLM) (23) and a few others. However, these approaches have different sensitivities for predicting changes in patients' conditions (24). ICF, otherwise, is not a functional scale, it goes further by being a classification of body structures and activities-participation domains that can provide a universal language of integral health status in different rehabilitation settings. The performance qualifier in ICF might indicate the extent of a problem during the execution of specific activities in an individual's current environment (25).

In 2003 the World Confederation for Physical Therapy (WCPT) endorses ICF as one of the principal frameworks for recording outcomes in physical therapy practice. In a hospital environment, ICF has been widely explored and contemplates the most relevant patient conditions managed by physical therapists in the acute and post-acute care settings (1). Previous studies have gathered the most common ICF categories presented in neurological, cardiopulmonary, and musculoskeletal issues and validated them into Core Sets used in hospital settings (26, 27). Furthermore, there are current international efforts to implement ICF in acute rehabilitation, including the use of the ICF Generic-30 Set and the short version, ICF Generic-7 Set.

Implementation of ICF may help clinicians to broaden their perspectives regarding patient functioning (28). To rate the severity of a problem in ICF components, the WHO proposes a qualifier scale rating 0–4 (0 no problem to 4 severe problems).

This system of classification is known as a generic scale and can be used in conjunction with first, second, and third qualifiers. It is possible to compare data from before and after treatments in a biopsychosocial model, considering patients' physical functioning, participation ability, and the influence of environmental factors (29). Zhang et al. (29) observed positive correlations between ICF qualifiers in the perspective of body structure, activity-participation, and environmental components with clinical assessment instruments for stroke, including the Modified Barthel Index and National Institutes of Health Stroke Scale, both commonly used in a hospital environment.

In EM protocols applied in intensive or intermediate care settings, ICF can help detect patients' activity demands, and consequently, help professionals manage the best inpatient rehabilitation program.

The primary aim of the present study was to analyze the activity level of neurological inpatients in admission and delivery after a Neurological Early Mobility Protocol (NEMP) in intermediate care settings in a public hospital in Brazil using Activity Level categories, HPMQ, and MBI scores. The secondary outcome is to analyze the ICF performance qualifier, specifically in the activity domain, transposing HPMQ and MBI scores to the corresponding ICF performance qualifier.

One hundred and twenty-nine patients were assessed by physiotherapists and 52 were eligible for NEMP after inclusion and exclusion criteria analysis (Figure 4).

Fifty-two patients were included with an age of 55 ± 20 (mean ± SD) years and a length of hospital stay of 33 ± 21 days. Fifty-two percent of patients were male and diagnostics varied between neuromuscular diseases (1), peripheral nerve injuries (5), and first motor neuron lesions (46). Comorbidities varied Systemic Arterial Hypertension (40%), Diabetes Mellitus (17%), Dyslipidemia (17%), and Atrial Fibrillation (14%). A major profile of patients is included in Table 4.

To make inferences in the ICF activity domain after a Neurological Early Mobility Protocol in an inpatients cohort, we analyzed three different evaluations: a) activity level (AL) to perform hospitals activities (5 categories); b) HPMQ which evaluates the level of assistance to perform hospitals activities (0–12); c) MBI classify the level of assistance of daily living Activity (0–100).

This study found that most neurologic patients in a public hospital in Brazil (Rio de Janeiro city), had low activity levels during hospital stay before an EM protocol. In all AL categories patients reached higher AL categories, except for AL 4, the most independent level. In AL 0, one patient had a potential improvement receiving discharge as AL4. In summary, categories with lower AL such as 0, 1, and 2 have lost their patients to the more independent groups, such as AL 3 and 4.

This data indicates that patients with neurological conditions might be responsive to NEMP, even though they have started the EM protocol out of the prescribed window observed in the literature (24–72 h). The same perspective can be represented with HPMQ scores, which revealed a statistically significant difference when comparing these two time points. The MBI scale also indicated changes in the construct as Severe Dependence improved to Moderate Dependence after intervention with NEMP.

Respecting the biomedical model, which is fixed in a specific diagnostic, the International Classification of Disease (ICD–WHO) does not change during the rehabilitation process. On the other hand, ICF will reflect functional status according to the different aspects of a patient's health. In our study, ICF showed improvements through performance qualifiers when recoded from HPMQ and MBI. Patients had qualifiers predominantly such as 2 and 3 (moderate to severe problems) at NEMP admission (data from HPMQ), which denotes moderate and severe problems. At discharge, qualifier 2 was the most common. This classification encourages the fact that the ICF performance qualifier might be useful to describe changes in the domain of activity, before and after interventions. The changes in (0–4) ICF scores were congruent with improvements observed in HPMQ. In orthostatism and walking items, for example, changes from severe problems to moderate problems were observed, demonstrating that NEMP can help patients to perform both tasks with less assistance.

In the present study, we used ICF Linking Rules from Cieza et al. (32) to recode activities from two instruments of functional measure into ICF. This linking process is important in allowing researchers to compare meaningful concepts contained in measure items more faithfully. Similarly, Prodinger et al. (34) worked to establish the equivalence of scores obtained from the FIM and MBI through ICF chapters of Mobility (d4) and Self-care (d5). The authors showed that the ICF Linking Rules could establish conceptual equivalence between these 2 scales through the application of ICF. In trials by García et al. (16), commonly used scales to measure walking activity post stroke were re-coded in ICF qualifiers. The trial demonstrated that the ICF generic score can be sensitive at detecting changes between the pre and post rehabilitation program directed to chronic stroke.

Besides starting after the interval considered as “early” in EM (first 24–72 h), patients were sensitive to NEMP. In the literature, the time to initiate EM usually varies from the first 24 to 72 h after ICUs admission or from stroke (10, 11). We implemented NEMP in ward settings, where physiotherapists are usually requested through a physician order before initiating rehabilitation. This delay is not inherent to the present study, Indredavik et al. (35), for example, observed that there was a delay of 2–3 days before the patient received the first physiotherapy/mobilization training in global wards, in comparison to stroke units. Despite the delay, NEMP was useful for improving the activity levels of inpatients in wards settings.

In the current study, data showed AL 2 as the most sensitive to NEMP intervention, especially for bathing, sitting at the edge of the bed, and sitting to stand transition in HPMQ activities. In MBI scores, patients in AL2 improved from severe to moderate dependency. This group was initially conducted to phase II of NEMP, where most exercises recruit the muscles of the trunk, facilitating the independence for these tasks. In the ICF performance qualifier, we observed improvements for the same activities of HPMQ in AL 2.

Categories as AL 1 and 3 exhibited progressions in constructs of MBI and the correspondent ICF performance qualifier. The AL 1 group showed significant statistical improvement when comparing pre and post NEMP intervention, with changes in total dependency construct to severe dependency in MBI (ICF qualifiers 4–3). In ICF data transposed from HPMQ in AL 1, bathing (3 to 2) and sitting at the edge of the bed (3 to 2) activities revealed favorable outcomes. AL 3 changed from severe to moderate dependency in MBI and correspondent changes in 3 to 2 in ICF. Recoding HPMQ scores into ICF, we had better qualifiers for bathing and orthostatism (both 3 to 2).

For patients in AL 4 group, there was no difference between the admission and discharge of NEMP in the MBI scale or HPMQ, except for the feeding item. There were no changes in ICF recodification from these scales, either. AL4 is characterized by a higher independence level, and they might have already reached the top of their functionality, with no changes in outcome. AL 0 (correspondent to phase I in NEMP) only had favorable outcomes for ICF performance qualifier for bathing and sitting at the edge of the bed, which is a favorable outcome as this latter activity is a criterion for progression to phase II in NEMP.

Rating the severity of functioning problems has been a challenge in the clinical field. Uhlig et al. (36) reported low reliability while examining the interrater reliability of clinician ratings using ICF qualifiers and the ICF core set for rheumatoid arthritis. Using a 0–4 qualifier rating scale alone, there is no guarantee that the scores have the same meaning among the various raters. For example, the problems in category b280 (sensation of pain) have different aspects as the intensity of pain, frequency, and the site of pain that can be interpreted differently among raters (28). Recoding ICF qualifiers through validated scales might be a good strategy to minimize different possibilities of rating 0–4 ICF scores.

The two instruments used in the current trial measure the level of assistance during the performance of activities also presents in chapters of Mobility and Self-care in ICF from WHO (25). The difference between both scales is that HPMQ analyzes activities commonly performed in a hospital environment, and MBI assesses the activity of daily lives. Furthermore, the HPMQ scale used “sitting at the edge of the bed,” “sit to stand” transition, and “orthostatism,” activities that are not inserted in MBI. These tasks are usually trained in EM protocols (7, 8, 10) so that inpatients can improve independence during important activities before being discharged home.

It is noteworthy that using the ICF improves communication between interdisciplinary teams from different fields, helping professionals undertake more holistic thinking when elaborating treatment programs (29). In the current study, the research implication is that NEMP might be useful in improving the activity levels of patients with neurological conditions, hospitalized in the wards of a public university hospital in Brazil. We hope that using the ICF first performance qualifier through recodification of validated scales will strengthen the applicability of ICF.

The delay in initiating NEMP compared to the period observed in the literature is considered a limitation, as well as the absence of a control group to compare data and the fact that the study was carried out at only one center.

Neurological patients hospitalized in wards have a low level of activity. In this study, data revealed an improvement in patients' AL after NEMP even if it was initiated after 72 h from hospital admission. The literature strongly recommended that EM protocols must be initiated within 48 h in stroke and other neurological disorders. This indicates a new time window for early rehabilitation in ward settings. NEMP reflected an alternative treatment that, despite being based on studies done in specialized ICUs and stroke units, revealed gains in mobility during hospitalization in wards.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by Hospital Universitário Clementino Fraga Filho-UFRJ CAAE 39932114.1.0000.5257. The patients/participants provided their written informed consent to participate in this study.

FL, AF, and IB contributed to the conception, design, and analysis of data for the work. VC contributed with data collection. FL wrote the manuscript and performed data analysis. All authors agree with the submission of this study.

This work was supported by the Higher Education Personnel Improvement Coordination (CAPES-Brazil).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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