Patients redefine early mobility after cardiac surgery, naming brain fog as the top barrier

For decades, the prescription after open-heart surgery has been surprisingly simple in concept: get the patient moving, and get them moving soon. Physiotherapists and nurses have long understood that early mobility through ambulation and bedside cycling improves physical health outcomes after cardiac surgery. Yet despite best-practice support, integrating early mobility into routine care in the cardiac surgery intensive care unit (CSICU) remains stubbornly underutilized. A new study from a Canadian research team suggests a provocative reason why: the patients themselves—the people who actually have to lift their bodies out of bed hours after their chest was opened—have rarely been asked what early mobility means to them, what stops them from doing it, and what would help them do it anyway.

The research, published in Frontiers in Rehabilitation Sciences as part of the Early mobility to improVE health outcomes following cardiac surgery (EVE) clinical trial development program, engaged ten people with lived experience of the CSICU—eight former patients and two care partners—through two virtual consultation workshops. The participants co-created a definition of early mobility, identified and prioritized barriers and facilitators, and ranked the outcome and experience measures that matter most to them. The work was reported using the GRIPP-2 long-form checklist, the international standard for documenting patient and public involvement in research, and the findings reconceptualize how early mobility should be defined, delivered, and evaluated in future intervention research.

The co-created definition is deceptively compact: early mobility is a progression of functional life activities that begins as soon as the patient can participate—typically within six hours post-surgery—where the patient uses their muscle strength intentionally. Each element carries technical weight. Progression acknowledges that mobility is not a single act but a spectrum of movements that build on one another, from standing at the bedside in the first hours after surgery to walking closer to discharge. Functional life activities expands the concept beyond walking or cycling to include the movements required to function at home: standing at a sink to brush one’s teeth, bathing, eating. Intentionally clarifies that early mobility requires purposeful movement with active muscle contraction, explicitly excluding passive range of motion and non-purposeful movements—something the authors note some healthcare providers have wrongly folded into their own definitions. Because the diagnosis of ICU-acquired weakness hinges on the strength of active muscle contraction, purposeful movement is precisely what prevents or overcomes that weakness, which is seen more often in patients with longer mechanical ventilation who are less likely to be mobilized out of bed.

The definition of early is equally deliberate. The participants initially offered definitions ranging from the day of surgery to after ICU discharge, but they reached consensus that early must be person-specific and tied to patient assessments and individual milestones rather than a fixed clock. Clinician members of the research team then added the tangible timeframe of typically within six hours post-surgery, a deadline designed to flip the clinical logic: instead of requiring criteria to justify mobilizing a patient, clinicians must now identify criteria to opt out. The six-hour window aligns with local guidelines and the published literature. The PWLE members of the team agreed with the addition, sharing that early had felt nebulous and could be deemed less important than other post-operative tasks; tying both time and ability to the concept gave it clinical meaning for everyone at the table. Importantly, no PWLE-identified elements were removed by clinicians—only additions occurred.

Then come the barriers, and the top-ranked one is not what most clinical checklists anticipate. The greatest obstacle to early mobility, according to the people who lived it, is brain fuzziness or fogginess—the cognitive haze that descends after anesthesia, ICU sedation, and the disorientation of critical care. The second and third barriers were paraphernalia—the lines, tubes, and drains that tether patients to bedsides—and weakness. None of these top barriers, the authors report, have been identified in the located CSICU early mobility literature. The prioritized facilitators are equally revealing: a positive attitude ranked first, followed by being encouraged, forced, helped, or reminded, and receiving education about pre-existing health issues interacting and causing unclear discomfort. The encouragement facilitator echoes findings from two other CSICU studies in which patients wanted motivation about the importance of early mobility, even to the point of nagging, and felt it was the healthcare provider’s role to get them moving. The paraphernalia barrier, by contrast, has been described before, and the literature offers strategies: locating lines and tubes in mobility-friendly positions, securing them, planning who monitors what during movement, and reassuring patients and families about the low rate of inadvertent removal reported in the literature.

The prioritized outcome measures expose a striking gap between what researchers typically measure and what patients actually experience. In existing early mobility studies, the most common outcome groups are hospital length of stay, pulmonary function, the six-minute walk test, hemodynamic measurements, heart rate variability, functional outcomes, and days to walk. Not a single one of the patient-prioritized outcomes appears among them. The top physical outcome was light-headedness or dizziness, followed by balance and confidence with mobility. The top cognitive outcome was head fuzziness or fogginess, followed by visual hallucinations and perceived confusion or hallucinations—the latter generated by a care partner asking whether a loved one seems confused or is hallucinating. The top mental outcomes were a positive outlook, anxiety, and a negative outlook. And the top experience measure was a question that cuts to the heart of patient-centred care: do you feel your doctors gave you the care and attention you needed? The second and third ranked experience measures asked the same of nurses and whether the care team asked how the patient was doing and listened to the answer.

The stakes are defined by post-intensive care syndrome (PICS), the constellation of new or worsening cognitive, mental, and/or physical health deterioration that follows an ICU stay. The research team’s previous scoping review found the incidence of PICS following cardiac surgery ranged from 16% to 99%—a bewildering spread that reflects the many symptoms composing each PICS domain and the diversity of tools used to measure them. With prevalence potentially that high, preventive interventions are urgently needed, and early mobility shows promise. But interventions cannot succeed as equal partnerships unless the people undergoing them participate willingly, and participation requires that the interventions be designed around their realities: short, clear, consistently repeated directions for patients navigating brain fog; mobility aides such as walkers for patients feeling weak; education and reassurance for patients and families that these symptoms are normal and that the care team will co-create a plan to address them.

The methodological machinery behind the findings deserves attention in its own right. The ten participants were recruited from a database of former cardiac surgery patients at St. Boniface Hospital in Winnipeg who had consented to future research contact, with inclusion criteria spanning coronary artery bypass grafting, valve surgery, or both within the past five years. The median age was 69 years, and the median CSICU length of stay was 5 days, though one participant’s stay reached 30 days. Two people self-identified as Métis, one of whom also identified as Ojibwe. Engagement followed the International Association for Public Participation’s Spectrum: two PWLE co-authors collaborated at the level of partnering in every aspect of research decisions, from planning meetings to co-facilitation, co-analysis, and co-authorship, while the additional ten consultants generated and prioritized the data through facilitated discussions and two rounds of the nominal group technique—a structured consensus method in which participants rank items independently, discuss the rankings, and re-rank, with Microsoft Forms capturing every change between rounds. The authors acknowledge limitations: the recruitment approach lacked focus on racial and ethnic diversity, all participants had surgery at the same hospital, and the study does not yet specify which validated tools should measure the prioritized outcomes—future research must align each concept with appropriate patient-reported outcome measures.

What makes this study resonate beyond rehabilitation science is its quiet challenge to the hierarchy of evidence. The most common outcome measures in early mobility research—walk tests, hemodynamics, length of stay—are the metrics systems can count. The outcomes patients prioritized—dizziness, brain fog, whether they are focusing on the positives in their life right now—are the metrics patients can feel. By co-creating a definition that begins within six hours of surgery and requires intentional muscle strength, and by naming brain fuzziness as the barrier that outranks every tube and drain, former cardiac surgery patients have handed researchers a blueprint for interventions that align with the perspectives and priorities of the people undergoing surgery. If the EVE feasibility trial and the studies that follow build on this foundation, the integration of early mobility into CSICU clinical care may finally advance—and the adverse cognitive, mental, and physical health outcomes that define PICS may become less prevalent for the hundreds of thousands of patients who pass through cardiac surgery intensive care units each year.

Subject of Research: Early mobility to improVE health outcomes following cardiac surgery (EVE) clinical trial development: findings from workshop 2—co-created definition and prioritized barriers, facilitators and outcome and experience measures

Article Title: Early mobility to improVE health outcomes following cardiac surgery (EVE) clinical trial development: findings from workshop 2—co-created definition and prioritized barriers, facilitators and outcome and experience measures

Article References: Phillips, E. K., Hay, J. L., Gregora, A., Smith, K., Chudyk, A. M., Shaski, C., Gilchrist, S., Fagan, A., Ashe, M. C., Schultz, A. S. H., Arora, R. C., Duhamel, T. A., & O’Keefe-McCarthy, S. (2026). Early mobility to improVE health outcomes following cardiac surgery (EVE) clinical trial development: findings from workshop 2—co-created definition and prioritized barriers, facilitators and outcome and experience measures. Frontiers in Rehabilitation Sciences, 7, Article 1801097. https://doi.org/10.3389/fresc.2026.1801097

Image Credits: AI Generated

DOI: 10.3389/fresc.2026.1801097

Keywords: Early, mobility, improVE, health, outcomes, following, cardiac, surgery, clinical, trial, development, findings