Systematic Review

Physiotherapy led early rehabilitation of the

patient with critical illness
Amanda J. Thomas
Department of Physiotherapy, The Royal London Hospital, UK

Background: Studies revealing the effectiveness of physical rehabilitation techniques provided during a
critical care admission have been hampered by experimental control issues and ethical constraints.
However, because of worldwide variations in physiotherapy practice, differences in patient outcomes can
be investigated when physical rehabilitation is provided immediately upon critical care admission
compared to rehabilitation initiated after extubation, after withdrawal of mechanical ventilation, after
discharge from the acute environment or not at all.
Objectives: The purpose of this review is to examine reports describing the effects of physical rehabilitation
which is commenced immediately on critical care admission compared to rehabilitation which is delayed.
Major findings: Overall, early initiation of rehabilitation reveals an increased incidence of physiotherapy
consultation, decreased time to achieve activity milestones, improved functional outcomes at intensive care
unit and hospital discharge and reduced direct patient costs. Where early rehabilitation is already a key
component of care for critically ill patients, research has concentrated on determining the acute
physiological effects of interventions, or the impact of providing additional specific therapies to overall
functional and administrative outcomes.
Conclusions: Early physiotherapy led rehabilitation of the critically ill patient has the potential to dramatically
influence recovery and functional outcomes in this vulnerable patient group.
Keywords: Critical illness, Intensive care, Critical care, Mobilization, Physiotherapy, Rehabilitation

Introduction physical morbidity delivered by professionals with

Unequivocal evidence reveals that individuals experi-
encing critical illness have high morbidity and a
marked decline in function.1,2 Critically ill patients
suffer profound impairments that may persist for
months following intensive care unit (ICU) admis-
sion. A survey of patients admitted to a Dutch ICU2
for more than 48 hours revealed that 12 months
following admission, 32% of subjects demonstrated
Sickness Impact Profile 68 scores suggesting clear
disablement in daily activities. Mobility revealed the
highest dysfunction (walking, managing hills, long
distances, and climbing stairs). Similar findings are
frequently reported within the post intensive care
literature3–6 and have prompted critical care commu-
nities to consider the optimization of physical
recovery as a key therapeutic objective in the care
of the critically ill, rather than just survival alone.
The increasing importance of this objective has led to
the publication of guidelines for rehabilitating critically
ill patients in the United Kingdom.7 These guidelines
recommend early assessment and management of
Correspondence to: A J Thomas, Department of Physiotherapy, The Royal
London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK.
Email: midaz_europe@hotmail.com
suitable competencies. Physiotherapists are ideally
suited for this role since their expertise as ‘movement
specialists’ provide the skills appropriate for safe
mobilization of the critically ill.8 The aim of this review
is to explore the evidence examining the effect of early
physiotherapy led rehabilitation for the patient with
critically illness.
Search Strategy
Database searches of MEDLINE (1966–May 2010),
CINAHL (1982–May 2010), EMBASE (1988–May
2010), The Cochrane Database of Systematic Reviews
and Cochrane Central Register of Controlled Trials
(The Cochrane Library, Issue 1, 2006), and PEDro
(1929–May 2010) were completed. The search terms
used included mobilization, rehabilitation, exercise
therapy, physiotherapy, ambulation, muscle strength,
functional training, functional recovery, mechanical
ventilation, intensive care, and critical care. Database
searches were supplemented by references from con-
ference proceedings, personal communication and by
hand searching. Emphasis for inclusion included those
publications comparing temporal variations in the
initiation of physical rehabilitation during a critical
care admission.

ß W. S. Maney & Son Ltd 2011

46 DOI 10.1179/1743288X10Y.0000000022 Physical Therapy Reviews 2011 VOL . 16 NO . 1

Results
Analysis of the retrieved data identified several
themes that could inform this review. Research was
grouped for consideration as follows:
1. definitions of physiotherapy led rehabilitation in
critical care;
2. worldwide differences in the provision of phy-
siotherapy led rehabilitation in critical care;
3. effects of rehabilitation compared to limited or no
rehabilitation;
4. early compared to later rehabilitation;
5. inclusion and exclusion criteria considerations;
6. standard physiotherapy management compared to
management including a specific rehabilitation
intervention;
7. the acute physiological effects of rehabilitation
interventions in critically ill subjects.
Definitions of Physiotherapy Led Rehabilitation
in Critical Care
The aim of physiotherapy within a critical care setting is
the optimization of cardiopulmonary function and the
prevention or treatment of the effects of immobility and
recumbency.9,10 Functional training is the treatment of
choice for physiotherapists in critical care following a
reduced need for respiratory physiotherapy8 and
published methods for facilitating walking in patients
requiring ventilator assistance first appeared 40 years
ago.11,12
Rehabilitation interventions in critically ill
patients, often labelled ‘mobilization’ refer to move-
ments, physical, or functional tasks that are sufficient
to elicit acute physiological effects on ventilation,
perfusion, and muscle metabolism.13 Stiller and
Phillips14 defined mobilization as ‘a hierarchy of
patient activities ranging from moving around the
bed to standing and walking’. Mobilization has been
recognized as an umbrella term for functional move-
ment defined according to its context of use, with a
hierarchy from low to high level tasks.15 Rehabi-
litation for ICU patients has been further defined by
a task force on physiotherapy for adult patients with
critical illness from the European Respiratory Society
and European Society of Intensive Care Medicine.16
Activities such as positioning, stretching, range of
motion exercise, splinting, functional mobilization,
aerobic training, and resistive exercise were recom-
mended to manage physical deconditioning and its
related complications.
Provision of Physiotherapy Led Rehabilitation
Notwithstanding these definitions, the provision of
physiotherapy led rehabilitation within critical care
varies widely throughout the world. Differences are
apparent between published practices in the United
Kingdom, Australia, Europe, and the United States of
America. For example, in a national survey of phy-
siotherapy practice within the United Kingdom, Lewis17
reported that 100% of surveyed physiotherapists offered
Thomas Physiotherapy led early rehabilitation of patient with critical illness
some form of rehabilitation to critically ill patients.
Rehabilitation activities included musculoskeletal assess-
ment and exercise prescription (100%), passive move-
ments (97%), tilt table use (86%), hoist use (90%), and
standing frames (59%).
In United Kingdom hospitals, physiotherapy is
routinely provided for critically ill patients and
includes both cardio-respiratory and neuro-muscu-
loskeletal management based on individualized asse-
ssment and autonomous decision making. Despite
this fact, there are few examples in the literature
documenting the incidence of rehabilitation in United
Kingdom critical care units. In an observational
study of physiotherapy practice for critically ill
patients in a London teaching hospital, active re-
habilitation techniques were employed during 55% of
all physiotherapy episodes over a 3-month period.18
Of these episodes, active assisted and active exercise
occurred with the greatest frequency (43 and 59%),
followed by sitting on the bed edge (36%), sitting
to standing (36%), and standing transfers (27%).
Similarly, Bahadur et al.19 reported that 63% of
mechanically ventilated patients requiring tracheost-
omy sat out of bed during their ICU stay in a London
teaching hospital.
An observational study of rehabilitation practice in
a French medical intensive care unit (MICU)20 where
rehabilitation eligibility was assessed daily by the
physician and physiotherapist in patients who had
received mechanical ventilation for greater than
2 days reported a low percentage of patients receiving
rehabilitation. Two hundred and twenty-five patients
were admitted over the 5-month observation period
but only 20 (9%) were enrolled in the early
rehabilitation program. Chair sitting was the most
common intervention completed (56%) followed by
tilt table standing (25%), standing frame use (8%),
and walking (11%).
Skinner et al.21 surveyed Australian physiothera-
pists regarding their ICU rehabilitation practice.
Most respondents (94%) prescribed exercise routi-
nely. Active and active assisted exercise ranked
highest, among other activities including sit to stand,
marching on the spot, sitting on the bed edge, and
walking. In 59% of surveyed units, physiotherapists
were responsible for deciding whether a patient
should exercise, while 22% relied on a team decision.
Medical staff were responsible for this decision in
only 17% of surveyed units. Consequentially, patients
received structured exercise in 83% of the surveyed
ICUs. A qualitative enquiry of Australian acute care
physiotherapists’ decision making15 reported ‘mobi-
lization’ as a first choice intervention within critical
care practice. Similarly, a survey completed by Chang
et al.22 revealed that Australian critical care phy-
siotherapists were proactive in the provision of early
Physical Therapy Reviews 2011 VOL . 16 NO . 1 47
Thomas Physiotherapy led early rehabilitation of patient with critical illness
mobilization strategies (standing, tilt table, sit out of
bed, and walking).
In contrast, American researchers have reported
the delivery of physiotherapy as infrequent and
occurring irregularly within their ICUs, which is
usually initiated by physician order.23 Describing
physical therapy practice at hospitals in Chicago and
Iowa, Schweickert et al.24 revealed that physiother-
apy was not provided routinely for patients ventilated
for less than 2 weeks nor were physiotherapists
dedicated for such practice. Needham et al.25
reported that only 27% of patients with acute lung
injury in three American hospitals ever received
physiotherapy while in ICU and therapy occurred
on only 6% of all ICU days. Hodgin et al.26 surveyed
critical care physiotherapy practice in American
hospitals and reported that 89% of surveyed ICUs
required a physician consultation to initiate phy-
siotherapy for critically ill patients. Only 1% of
hospitals had automatic physiotherapy evaluation of
patients admitted to ICU.
The differences in international critical care phy-
siotherapy practice provide a unique opportunity to
appreciate the role of physical rehabilitation for
critically ill patients. Since it is unethical to deny a
critically ill patient the opportunity to receive rehabi-
litation in those units where physiotherapy led
rehabilitation is standard practice, evaluation of the
introduction of rehabilitation to those patients who
would not normally receive physiotherapy, or who
would receive physiotherapy later in their critical care
stay is favoured.
Rehabilitation Compared to Limited or No
Rehabilitation
An early randomized trial of physical rehabilitation
in a critical care environment,27 compared standard
therapy and progressive ambulation with a compre-
hensive physical rehabilitation program in stable
patients with severe chronic obstructive pulmonary
disease (COPD; forced expiratory volume in one
second 31–33% predicted). The majority of the cohort
were ventilated (78% intervention and 70% controls)
on admission to the respiratory intensive care unit
(RICU), and had been intubated for respiratory
failure 5–19 days prior to study enrolment. Inter-
vention subjects (n560) received twice daily rehabi-
litation progressing from bed exercise (step I) to
walking retraining (step II), respiratory muscle
training, stationary cycling, and stair climbing (step
III) and 2630 minutes daily sessions of treadmill
walking (step IV). The control group (n520) com-
pleted steps I and II only.
Comprehensive rehabilitation elicited a 120%
increase in 6-minute walk distance at hospital discharge
compared to the first time patients were able to walk on
48 Physical Therapy Reviews 2011 VOL . 16 NO .
their own (P,0.0001), while progressive ambulation
elicited a non-significant 52% increase in distance
walked. Both intervention and control subjects reported
significant reductions (P,0.001 and P,0.05 respec-
tively) in admission dyspnoea assessed on a visual scale
on hospital discharge. Despite the improvements in
walking endurance and breathlessness, length of stay in
the RICU was longer for the intervention group
(38.1¡14.3 days) compared to controls (33.2¡
11.7 days) and the intervention did not influence
survival.
A small study conducted in Taiwan28 revealed
dramatic differences within mechanically ventilated
patients who received a 6-week rehabilitation pro-
gram, and those who received verbal encouragement
to exercise only. Subjects with respiratory failure
requiring prolonged mechanical ventilation (greater
than 45 days) were alternately assigned to an inter-
vention or control group. Intervention subjects
(n517) received therapy five times a week for
6 weeks. Training consisted of bedside strengthening
exercise progressing to resistance and weights as
strength improved. Functional training progressed
from bed mobility to transfers, standing and walking
as tolerance allowed. Control patients (n515)
received standard care including assistance with
activities of daily living but no physiotherapy. It is
presumed from an ethical perspective that phy-
siotherapy was not routinely provided within this
ICU and that the intervention was a novel therapy.
Over the study period, intervention participants
improved peripheral and respiratory muscle strength
compared to baseline. In contrast, limb and respira-
tory muscle strength significantly deteriorated com-
pared to baseline in the control group. Fifty-three
percent of the intervention group regained some
ability to ambulate (2-minute walk distance 42.9¡
12.7 m, n59) after 6 weeks of physical training but
control subjects remained unable to ambulate at
study conclusion. Differences in respiratory muscle
endurance were expressed through an increased
ventilator free time in the intervention group
(8.9 hours) compared to controls (4.8 hours). Func-
tional ability expressed by Barthel index and func-
tional independence measures improved significantly
in the intervention group compared to the control
subjects at the 6-week interval.
Whole body physical rehabilitation programs have
previously demonstrated beneficial effects in groups
of long term mechanically ventilated respiratory
failure patients;29,30 however, in these studies patients
have acted as their own controls. Until the work by
Chiang et al.,28 there has never been convincing
evidence of the detrimental effect elicited by an
absence of physical rehabilitation in ventilated
respiratory failure patients.
1

Early Compared to Later Rehabilitation
Reports arising from investigations conducted within
hospitals in the United States illustrate the effects of
early rehabilitation of critically ill patients. The term
‘early’ in this context is defined as either the point of
initial physiological stability31,32 or immediate enrol-
ment in a protocol driven mobility program on ICU
admission.23 These models can be contrasted with
usual care that may delay the initiation of rehabilita-
tion until physician referral or ICU discharge. A
summary of these studies is provided in Table 1.
In one example, Bailey et al.31 described a pro-
spective study of respiratory failure patients admitted
to an RICU from other ICUs within in the same
hospital. Subjects were assessed within 24 hours
of RICU admission and then daily for physi-
ological stability with a priori criteria (see Table 1).
Patients meeting the criteria were immediately com-
menced on the early activity protocol which progres-
sively increased rehabilitation until discharge from
the RICU.
These authors introduced the concept of ‘time to
activity milestones’ as a metric of activity perfor-
mance in critically ill patient groups. Bailey et al.31
report that the time to activity from initial ICU stay
in their early activity cohort was 6.6¡5.5 days to sit
on the bed edge, 8.8¡7.6 days to sit in a chair,
11.3¡10.1 days to walk, and 12.4¡10.7 days to walk
greater than 100 ft. The time to activity from actual
RICU admission was 22.9¡7.7 days to sit on the
bed edge, 20.7¡7.5 days to chair sit, 1.5¡9.1 days
to walk, and 2.9¡9.4 days to walk greater than
100 ft. Negative numbers for sitting activities reveal
that these tasks had been completed prior to RICU
transfer but positive numbers for walking suggest
that ambulation was facilitated by the RICU activity
regime. At the end of the RICU stay only 2.4% of the
cohort had not been mobilized and 69% of partici-
pants had ambulated greater than 100 ft.
The promotion of intense activity following trans-
fer to an RICU was further demonstrated by
Thomsen et al.32 in an investigation of activity events
occurring before and after transfer to an RICU. In
this study, subjects commenced activity on admission
to the RICU according to the stability criteria pre-
viously established.31
In the 24 hours preceding RICU transfer, only 11%
of the patients had achieved ambulation. In contrast,
28% of patients were ambulating after 24 hours in the
RICU and 41% were ambulating 48 hours after
transfer (P,0.0001). Ambulation ability was not
explained by improved underlying physiology and
regression analysis revealed that RICU transfer was
the strongest single predictor of ambulation (odds
ratio 2.47; 95% confidence interval 1.9–3.4;
P,0.0001). The authors attributed their findings to
Thomas Physiotherapy led early rehabilitation of patient with critical illness
a culture where early mobility is a priority and key
component of patient care and suggested that when
given the opportunity, ventilated patients are able to
substantially increase their activity levels.
In both studies discussed above, rehabilitation was
commenced following transfer to an ICU that
prioritized mobility. It is important to recognize that
patients were admitted to this unit following a mean
of 10.3¡7.5 days30 and 10.5¡9.9 days29 respec-
tively, whereby the cohort had been experiencing an
intensive care admission but not a structured activity
program. Investigations of activity metrics when
rehabilitation protocols are commenced immediately
on ICU admission are required.
To this end, Morris et al.23 report a prospective
study which compared an immediate mobility proto-
col with usual care in ventilated adults from MICU
who survived to hospital discharge. Three hundred
and thirty subjects met the study criteria and were
block allocated to either the protocol group (n5165)
or usual care group (n5165).
In the protocol group, physiotherapy was immedi-
ately initiated with treatments provided 7 days per
week at a level determined by the patient’s ability to
interact and limb strength (see Table 1). The mobility
protocol continued until discharge from the MICU.
Subjects in the usual care group received daily passive
range of motion and second hourly repositioning.
Physiotherapy was initiated in the control group
following physician order and was available 5 days
per week.
Eighty percent (n5116) of patients in the protocol
group received at least one session of physiotherapy
during their hospital stay compared to 47.4% (n564)
of the usual care group. Of the patients who received
physiotherapy in the usual care group, 12.5% received
therapy during MICU admission compared to 91.4%
of protocol patients (P,0.001). Time to activity was
interpreted as ‘days to first out of bed’ in which the
protocol group had fewer days (8.5 days) than the
usual care group (13.7 days, P,0.001). Days of
mechanical ventilation were not different between
groups but when MICU stay was adjusted for body
mass index, acute physiology and chronic health
evaluation II scores, and vasopressor use, protocol
subjects demonstrated fewer ICU days (5.5 days)
than controls (6.9 days, P50.25). Similarly, adjusted
hospital length of stay was shorter for protocol
subjects (11.2 versus 14.5 days, P50.006).
Of interest in this study was the cost analysis which
revealed that protocol costs ($6 805 082) inclusive of
mobility team salaries were less than usual care costs
($7 309 871). The differential was likely produced by
the decrease in MICU and hospital length of stay.
Although cost differences were not significant
(P50.262), an early mobility protocol that facilitated
Physical Therapy Reviews 2011 VOL . 16 NO . 1 49
50
Thomas

Table 1 Summary of early rehabilitation in intensive care intervention studies

Criteria to
Authors Study Participants initiate activity Interventions Outcomes

Physical Therapy Reviews

Bailey Prospective 103 respiratory failure Assessed daily Twice daily physiotherapy Activity metrics
et al.31 cohort patients requiring FiO2,0.06 Progressive increase in 1449 activity events:
MV .4 days PEEP,10 cmH2O activity level from sit in Sit on bed: 233 (16%)

2011
Median age: 63 years Absence of orthostatic chair to ambulation Sit on chair: 454 (31%)
(range: 50–75 years) hypotension Ambulate: 762 (53%)
Diagnoses (n) Absence of Time to activity from initial

VOL .
Sepsis541 catecholamine drips ICU admission:

16
Pneumonia520 Patient response to Sit on bed edge: 6.6¡5.5 days
CV disease510 verbal stimulation Sit on chair: 8.8¡7.6 days

NO .
Aspiration57 Walk: 11.3¡10.1 days

1
GI bleed/liver failure56 Walk .100 ft: 12.4¡10.7 days
Trauma56 Time to activity from RICU admission:
Surgery56 Sit on bed edge: 22.9¡7.7 days
Exacerbated COPD54 Sit on chair: 20.7¡7.5 days
Physiotherapy led early rehabilitation of patient with critical illness

Cancer52 Walk: 1.5¡9.1 days

Asthma51 Walk .100 ft: 2.9¡9.4 days
Thomsen Pre–post- 104 respiratory failure Assessed daily Twice daily physiotherapy % patient activities 24 hours pre-RICU
et al.32 cohort patients requiring MV .4 FiO2,0.06 Progressive increase in activity versus 24 hours post-RICU transfer
days hospitalized for .2 days PEEP,10 cmH2O level from sit in chair to ambulation No activity: 21% pre-RICU versus 3%
prior to RICU transfer Absence of orthostatic Control: activity events post-RICU
Median age: 55.9 years hypotension occurring in the 2 days prior to ROM: 15% pre-RICU versus 4%
(range: 20–89 years) Absence of RICU transfer (each patient served post-RICU
Diagnoses (n) catecholamine drips as their own control) Sit on bed edge: 34% pre-RICU
Sepsis540 Patient response to versus 35%
Pneumonia517 verbal stimulation post-RICU
CV disease515 Sit in chair: 21% pre-RICU versus 32%
Trauma510 post-RICU
GI bleed/liver failure59 Ambulate .100 ft: 7% pre-RICU versus
Surgery55 12% post-RICU
Aspiration52 Predictors of increased ambulation
Cancer52 RICU transfer (OR 2.47; 95% CI
Exacerbated COPD51 1.85–3.4; P,0.0001)
Asthma51 Absence of sedatives (OR 1.9; 95%
Pulmonary embolism51 CI 1.19–3.15; P50.009)
Renal disease51 Female gender (OR 1.88; 95%
CI 1.11–3.22; P50.019)
Lower APACHE II score
(OR 1.06; 95%
CI 1.01–1.12; P50.017)
 Table 1 Continued

Criteria to
Authors Study Participants initiate activity Interventions Outcomes

Morris Prospective Patients assessed within Intervention: immediate Intervention: 7 days per week mobility % patients receiving physiotherapy during
et al.23 cohort comparing 48 hours of intubation and start (day 1) at first service offering a four level graded hospital stay: 80% protocol versus 47.4%
early ICU 72 hours of admission level then assessment activity protocol control (P,0.001)
mobilization over 24 months of ‘readiness to interact’ Level 1: passive ROM 36 daily to % patients receiving physiotherapy during
versus usual Intervention: n5165, for progression to level 2; upper and lower peripheral joints ICU admission: 91.4% protocol versus
care mean age 54.0¡16.8 years MRC 3/5 biceps for level Level 2: introduced active assisted 12.5% (P,0.001)
Diagnoses (n): 2–3 advance; 3/5 quadriceps and active ROM exercise (no weights), Activity metrics
Pneumonia532 for level 3–4 advance and sitting position 3620 minutes Days to first out of bed: protocol 8.5 days
Sepsis526 Control: physician patient Level 3: introduced sitting on bed (6.6–10.5 days) versus control 13.7 days
Aspiration527 specific order edge, other activities continued (11.7–15.7 days), P,0.001
Pancreatitis54 Level 4: introduced active transfers Days to first out of bed adjusted for BMI,
Other ALI56 to chair, pre-gait activities in standing APACHE II, and vasopressor use: protocol 5
Coma525 and ambulation. Other activities continued. days (4.3–5.9 days) versus control 11.3 days
Surgery57 (9.6–13.4 days, P,0.001)
CCF512 Administrative data
Cardiac arrest53 ICU LOS days: protocol 7.6 days
Asthma54 (6.3–8.8 days) versus control 8.1 days
COPD514 (7.0–9.3 days, P50.84)
Acute on chronic lung ICU LOS days adjusted for BMI, APACHE II,
Thomas

disease52 and vasopressor use: protocol 5.5 days

Control: n5165, mean (4.7–6.3 days) versus control 6.9 days
age 55.4¡16.8 years Control: daily passive ROM delivered (5.9–8.0 days, P50.025)
Diagnoses (n): by bedside nurse and physiotherapy Hospital LOS days: protocol 14.9 days
Pneumonia533 initiated by physician referral but not (12.6–17.1 days) versus control 17.2 days
Sepsis523 defined. (14.2–20.2 days, P50.48)
Aspiration532 Hospital LOS days adjusted for BMI, APACHE II,
Pancreatitis52 and vasopressor use: protocol 11.2 days
Other ALI510 (9.7–12.8 days) versus control 14.5 days
Coma520 (12.7–16.7 days, P50.006)
Surgery54 Average cost per patient: protocol inclusive

Physical Therapy Reviews

CCF510 of mobility team salaries $41 142 versus
Cardiac arrest56 control $44 302 (P50.262)
Asthma54

2011
COPD518
Acute on chronic lung
disease52

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Physiotherapy led early rehabilitation of patient with critical illness
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Thomas

Table 1 Continued

Criteria to
Authors Study Participants initiate activity Interventions Outcomes

Physical Therapy Reviews

Schweickert Prospective MICU patients ventilated Intervention: began on Intervention: physiotherapy and occupational Delivered therapy
et al.24 randomized ,72 hours in two medical day of enrolment therapy co-ordinated with daily interruption Therapy delivered during intubation:
control trial centres randomly assigned Control: therapy delivered of sedation. Unresponsive patients received intervention 0.32 hours/day versus control
1 : 1 ratio over 5-month period following orders from primary passive ROM exercise. Once patient interaction 0.0 hours/day (P,0.0001)

2011
Intervention: n549, median care team was achieved intervention advanced to active Days from intubation to first therapy session:
age 57.7 years (range: assisted and active exercise, bed mobility, intervention 1.5 days (1.0–2.1 days) versus
36.3–69.1 years ADL practice, transfers, pre-gait exercises, control 7.4 days (6.0–10.9 days), P,0.0001

VOL .
Diagnoses (n) and walking. Therapy continued through Activity metrics

16
ALI527 to hospital discharge if required. Days from intubation to milestones achieved:
Exacerbated COPD54 Out of bed: intervention 1.7 days (1.1–3 days)

NO .
Asthma55 versus control 6.6 days (4.2–8.3 days), P,0.0001

1
Sepsis57 Standing: intervention 3.2 days (1.5–5.6 days)
Haemorrhage51 versus control 6.0 days (4.5–8.9 days), P,0.0001
Cancer52 Marching in place: 3.3 days (1.6–5.8 days)
Other53 versus control 6.2 days (4.5–8.4 days), P,0.0001
Physiotherapy led early rehabilitation of patient with critical illness

Control: n555, median age Transferring to a chair: intervention 3.1 days

54.4 years (range: Control: not described (1.8–4.5 days) versus control 6.2 days (4.5–8.4 days),
46.5–66.4 years P,0.0001
Diagnoses (n) Walking: intervention 3.8 days (1.9–5.8 days) versus
ALI531 7.3 days (4.9–9.6 days), P,0.0001
Exacerbated COPD56 Functional outcomes
Asthma54 Hospital discharge BI score: intervention
Sepsis59 75 (7.5–95) versus control 55 (0–85), P50.05
Haemorrhage52 ICU acquired paresis at hospital discharge:
Cancer51 intervention 31% versus control 49%, P50.09
Other52 Hospital days with delirium: intervention 28%
versus control 41%, P50.01
Administrative data
ITU LOS days: intervention 5.9 days
(4.5–13.2 days)
versus control 7.9 days (6.1–12.9 days),
P50.08
Hospital LOS days: intervention 13.5 days
(8.0–23.1 days) versus control
12.9 days (8.9–19.1 days), P50.93

Note: RICU5respiratory intensive care unit; MV5mechanical ventilation; CV5cardiovascular disease; COPD5chronic obstructive pulmonary disease; ALI5acute lung injury; CCF5congestive cardiac failure;
FiO25fraction of inspired oxygen; PEEP5positive end expiratory pressure; ROM5range of motion; OR5odds ratio; CI5confidence interval; APACHE II5acute physiology and chronic health evaluation score;
MRC5medical research council strength; LOS5length of stay; kg/m25kilogram per metres squared; ADL5activities of daily living; hours/day5hours per day; BI5Barthel index score; GI5 gastrointestinal;
ITU5intensive therapy unit.

increased physiotherapy led rehabilitation for critical
ill subjects may be a cost saving intervention. It
remains unknown what effect continuing the mobility
protocol beyond the MICU stay may have on both
functional and economic outcomes.
To further elucidate this issue, Schweickert et al.24
report a randomized trial comparing physical and
occupational therapy delivered from the inception of
respiratory failure requiring mechanical ventilation
(n549) with physician ordered physical and occupa-
tional therapy typically occurring after extubation
(n555). This study is unique compared to others
since mobilization started very early, continuing
throughout the acute hospital stay, and the investi-
gators measured functional outcomes.
Daily screening identified adults ventilated for
greater than 72 hours who met the criteria of baseline
functional independence (derived from a proxy
Bartell index score greater than 70 in the 2 weeks
prior to admission). Intervention subjects received a
progressive therapy regimen focused on mobilization
and activities of daily (see Table 1). In contrast to
previous studies, therapy continued until subjects had
achieved their previous level of function or were
discharged from the hospital. Control subjects were
provided with physical and occupational therapy as
ordered by the physician.
Ninety-four percent of the intervention group
received therapy on 87% of study days. The median
duration of therapy during mechanical ventilation was
greater in the intervention group compared to controls
(0.32 versus 0.0 hours, P,0.0001). Therapy began
1.5 days after intubation in the intervention subjects
and 7.4 days after intubation in the control group
(P,0.0001). Since the median length of ICU stay was
7.9 days, control patients started therapy just prior to
ICU discharge. Time to functional milestones was
significantly improved for intervention subjects com-
pared to controls. Standing occurred 3.2 days (range:
1.5–5.6 days) following intubation in intervention
subjects compared to 6.0 days (range: 4.5–8.9 days)
in controls (P,0.0001). Similarly, transferring to a
chair occurred at 3.1 days (range: 1.8–4.5 days) in the
intervention group and 6.2 days (range: 4.5–8.4 days)
in controls (P,0.0001).
Subjects in the intervention group had significantly
higher functional ability scores and greater walking
distances (33 versus 0 m, P,0.004) compared to
controls at hospital discharge. Return to independent
function at hospital discharge occurred in 59% of
intervention subjects compared to 35% of controls.
Despite the improved physical outcomes in the
intervention group, length of stay in the ICU and
hospital did not differ between groups. Significantly,
this study revealed improved intensive care (P50.03)
and hospital delirium scores (P50.02) in the
Thomas Physiotherapy led early rehabilitation of patient with critical illness
intervention group despite the fact that sedation
and analgesia levels were similar between groups. The
authors suggest that delirium and physical function
are undoubtedly linked.
The relationship between sedation, delirium, and
physical function in ventilated patients has recently
been explored in a report from a 16-bed MICU in
Baltimore.33 Patients were included if they were
cognitively intact, without neuromuscular disease
and required mechanical ventilation for greater than
4 days. Data were collected regarding benzodiazepine
and narcotic use, sedation and delirium status, pain,
and number of rehabilitation consultations in a 3-
month period prior to, and in the 4 months following
implementation of a multidisciplinary improvement
project.
The project involved education regarding the
detrimental neuromuscular effects of critical illness,
early mobility interventions, and sedation issues.
Process changes included the development of mobi-
lity guidelines, and guidelines for therapy and
rehabilitative medicine referrals. The availability of
therapy within the unit was increased and a change in
sedation practice from continuous to bolus dose was
encouraged.
Despite the fact that eligible patients represented
only 10% of all MICU admissions during each of the
time periods, project implementation elicited lower
proportions of patients receiving sedatives during the
MICU stay. Patients were more frequently alert and
not delirious during the MICU stay compared to the
control period. Consequently, more patients received
therapy post-implementation (93%) compared to pre-
implementation (70%, P50.04). A 286% increase in
therapy treatments was delivered following project
implementation and functional mobility levels of
sitting or higher occurred with a greater frequency
(56% pre and 78% post, P50.03). Although func-
tional outcomes were not reported, mean MICU
length of stay was decreased from 7.0 to 4.9 days
(P50.02) following project implementation.
Similarly, mean hospital length of stay decreased
from 17.2 to 14.1 days (P50.03) despite a 20%
increase in MICU admissions across the two time
periods.
Inclusion and Exclusion Criteria
It is important to recognize that the aforementioned
studies excluded significant numbers of patients and
their results cannot be assumed to be applicable to all
critically ill patients. Morris et al.23 excluded patients
who were unable to walk without assistance prior to
ICU admission, had a body mass index greater than
45, or whose current hospitalization was greater
than 72 hours. Schweickert et al.24 excluded subjects
with poor functional independence prior to ICU
Physical Therapy Reviews 2011 VOL . 16 NO . 1 53
Thomas Physiotherapy led early rehabilitation of patient with critical illness
admission and those with amputated limbs. The
complete inclusion and exclusion criteria for these
studies are detailed in Table 2. It may be argued that
excluded patient groups were at risk of greater
physical morbidity as a result of their ICU stay and
represent a higher priority for early rehabilitation
than other individuals. In addition, the median length
of intensive therapy unit stay reported by both
Morris et al.23 and Schweickert et al.24 was between
6 and 9 days only. The impressive results of these
studies cannot be generalized to patients with an
expected prolonged critical care stay.
It therefore remains unclear how activity strategies
started immediately on ICU admission may affect a
critical care population in which all patients are
assessed for the possibility of receiving physiother-
apy. A small observational study within a general/
trauma ICU in the United Kingdom34 reported mean
time to activity milestones comparable with those
reported by Bailey et al.31 and earlier than those
reported by Morris et al.23 In this ICU physiotherapy
is routinely provided and therapists make daily
decisions regarding the potential to commence
mobilization in all patients admitted to the unit,
regardless of their history, body mass index, or
presenting illness. Further investigations illustrating
activity metrics in all critically ill patients may reveal
which populations benefit from early rehabilitation.
Table 2 Inclusion and exclusion criteria for early mobilization studies
Investigator Inclusion criteria
Morris $ MICU.
et al.23 $ Age .18 years.
$ Mechanically ventilated via
endotracheal tube ,48 hours.
$ Admission to MICU ,72 hours.
$ Survival to hospital discharge.
Schweickert $ MICU.
et al.24 $ Age .18 years.
$ Mechanical ventilation
,72 hours expected to
continue for at least 24 hours.
$ Baseline functional
independence
assessed as BI.70
obtained from
a proxy describing
patient function
2 weeks before admission.
Note: ICU5intensive care unit; MICU5medical intensive care unit; BMI5body mass index; ICP5intracranial pressure.
54 Physical Therapy Reviews 2011 VOL . 16 NO .
Standard Physiotherapy Plus Specific
Interventions
Where physiotherapy led rehabilitation is a standard
component of ICU management, research endea-
vours are concerned with the effectiveness of specific
interventions provided in addition to routine care.
Zanotti et al.35 reported the effects of a small
randomized trial of respiratory failure subjects with
COPD who had been mechanically ventilated and
confined to bed for at least 30 days. Intervention
subjects (n512) received 30 minutes of electrical
stimulation via surface electrodes positioned bilater-
ally on quadriceps femoris and vastus glutei.
Stimulation was provided twice daily, five times per
week over a 4-week period in addition to active limb
mobilization. Control subjects (n512) received active
limb mobilization alone.
At the conclusion of the study, intervention
subjects significantly increased muscle strength scores
compared to control subjects (2.16¡1.02 versus
1.25¡0.75, P50.02). Electrically stimulated muscle
contractions elicited a shortened time for patients to
mobilize from bed to chair (10.75¡2.41 versus
14.33¡2.53 days) compared to active limb mobiliza-
tion alone.
More recently, ICU patients in Greece with
mechanical ventilation durations less than 10 days,
who received daily electrical stimulation of the
Exclusion criteria
$ Inability to walk without assistance before acute ICU illness.
$ Cognitive impairment before acute ICU illness (non-verbal).
$ Preadmission immune-compromised status
(prednisolone .20 mg/day for 2 weeks).
$ Neuromuscular disease that could impair weaning
(myasthenia gravis, amyotrophic lateral sclerosis, and Guillian-Barre).
$ Acute stroke.
$ BMI.45.
$ Hip fracture.
$ Unstable cervical spine or pathological fracture.
$ Mechanical ventilation .48 hours before transfer from
an outside facility.
$ Current hospitalization or transferring hospital stay .72 hours.
$ Cardiopulmonary resuscitation at admission.
$ Do not resuscitate order at admission.
$ Hospitalization within 30 days before admission.
$ Cancer therapy within the last 6 months.
$ Readmission to ICU within current hospitalization
$ Rapidly developing neuromuscular disease.
$ Cardiopulmonary arrest.
$ Irreversible disorders with 6-month mortality estimated at .50%.
$ Raised ICP.
$ Absent limbs.
$ Enrolment in another trial.
1

quadriceps and peroneus longus from the second day
of admission demonstrated preserved cross-sectional
diameter of quadriceps compared to controls.36
Despite the fact that muscle strength and functional
ability were not assessed in this study, preservation of
muscle mass in critically ill patients who are unable to
participate in active exercise may delay skeletal
muscle protein loss and preserve muscular perfor-
mance. Electrical stimulation has been previously
demonstrated to elicit improved muscle strength in
healthy adults,37 populations with heart failure38 and
moderate to severe COPD.39,40
Evidence has also emerged suggesting that elec-
trically stimulated muscle contraction in selected
critically ill populations may prevent the development
of critical illness polyneuromyopathy (CIPNM).
Routsi et al.41 describe a randomized parallel
intervention in which mechanically ventilated
patients were allocated to receive daily sessions of
electrical stimulation to thigh musculature within
48 hours of critical care admission until ICU
discharge (n524) or a control group (n528). The
diagnosis of CIPMN was determined by a medical
research council strength score of less than 48 of 60
assessed on the first day patients could co-operate
with examiners.
Intervention subjects demonstrated a lower inci-
dence of CIPMN (12.5%) compared to controls
(39%) and higher medical research council strength
scores compared to controls (median 58 versus 52,
P50.04). Weaning periods for subjects assigned
electrical stimulation was also shorter than the
control group. Although mean length of stay in the
ICU was shorter in the intervention group than
controls (14 versus 22 days) this difference was not
significant.
Routsi et al.41 suggest that electrical stimulation
may provide an anabolic stimulus capable of rever-
sing the catabolic effects of critical illness and
immobility in select patient groups. Further research
is required to appreciate the mechanisms underlying
these findings but neuromuscular stimulation is
recommended by the European Respiratory Society
and European Society of Intensive Care Medicine16
as an adjunct for the rehabilitation of critically ill
patients at risk of musculoskeletal dysfunction.
The effects of daily cycle ergometry in addition to
standard physiotherapy management on critically ill
patients have also been reported.42 Patients were
assessed on the fifth ICU day and randomized to an
intervention (n545) or control group (n545). Both
groups received standardized therapy progressing
from passive movements to functional activities and
ambulation as tolerance allowed. In addition, inter-
vention subjects received 20 minutes of recumbent
cycling daily. The ergometer provided passive cycling
Thomas Physiotherapy led early rehabilitation of patient with critical illness
for those patients who were sedated and six levels of
resistance for subjects who could actively participate.
Treatments were provided for the duration of the
ICU stay.
At ICU discharge there were no significant
differences between intervention and control subjects
in ability to stand (34 versus 23%, P50.4) or walk (10
versus 14%, P50.72). Weaning time, ICU, and
hospital length of stay were not different between
the two groups. However, at hospital discharge,
recumbent cycling elicited improvements in median 6-
minute walk distance (196 versus 143 m, P,0.05) and
Short Form 36 physical function (P,0.01). Qua-
driceps muscle force improved more between ICU
and hospital discharge for intervention subjects
(1.83¡0.91 versus 2.37¡0.62 N/kg, P,0.01) than
controls (1.86¡0.78 versus 2.03¡0.75 N/kg,
P50.11). While the addition of 20 minutes of cycling
did not affect functional outcomes at ICU discharge,
exposure to the intervention clearly enhanced the
benefit of ward rehabilitation.
It remains unknown whether improvements
reported by Burtin et al.42 are unique to the cycling
intervention, or could be elicited through the addition
of any physical activity. A pilot investigation from
Scotland43 reported that enhancing standard phy-
siotherapy with interventions delivered by a rehabi-
litation assistant increased physiotherapy frequency
from 2.6 to 8.2 sessions per week, allowing a greater
incidence of mobility treatments (3.3 to 14.6 per
week). Three months follow-up revealed no differ-
ences between the standard and enhanced service in a
battery of physical function tests although the small
numbers reviewed (n58) prevented meaningful com-
parisons. The effect of complex physical rehabilita-
tion interventions in the immediate post-critical care
period remains largely unexplored and definitive
investigations will require significant recruitment.
Acute Effects of Physical Interventions
Reports from ICUs where early rehabilitation is
practiced routinely have been concerned with appre-
ciating the acute physiological effects of interven-
tions. For example, active standing elicited increases
over baseline minute ventilation (41%), tidal volume
(24%), and respiratory rate (16%) in ventilated
abdominal surgical patients progressively mobilized
from supine, sitting on the bed edge, and standing.44
Similarly, passive standing on a tilt table elicited
increases in minute ventilation (27%), tidal volume
(17%), and respiratory rate (19%) when compared to
supine baseline in a mixed sample of spontaneously
breathing and ventilated critically ill patients.45
Discreet physiological effects of specific interven-
tions have also been reported by Bourdin et al.20
Physiological recordings were made at the start and
Physical Therapy Reviews 2011 VOL . 16 NO . 1 55
Thomas Physiotherapy led early rehabilitation of patient with critical illness
end of four rehabilitation interventions in 20 MICU
patients with acute respiratory failure. Chair sitting
for 1–2 hours elicited decreases in heart rate
(23.5 beats/minute, P50.03) and respiratory rate
(21.4 breaths/minute, P50.03). Standing on a tilt
table for 15 minutes increased heart rate (14.6 beats/
minute, P,0.001) and respiratory rate (5.5 breaths/
minute, P,0.001) and decreased oxygen saturation
(20.9%, P,001) while use of a standing frame for
10 minutes elicited increases in heart rate (12.4 beats/
minute, P,0.001) and mean arterial pressure
(8.9 mmHg, P50.01). Walking a median distance of
80 m increased heart rate (6.9 beats/minute,
P50.002) and respiratory rate (5.9 breaths/minute,
P,0.001) but lowered oxygen saturation (21.4%,
P5001). It remains unclear whether the small
physiological changes reported were clinically sig-
nificant, or what mechanisms were responsible for the
observed changes.
An appreciation of the metabolic requirements of
rehabilitation interventions has been reported in a
small study of ventilated critically ill patients (n510)
which confirmed that standing on a tilt table and
sitting in a chair elicited significant increases in
oxygen consumption (VO2) and minute ventilation
compared to baseline.46 Further investigations of this
nature will increase our appreciation of the effective-
ness of dose-dependant exercise prescription in these
patient groups.30
Recommendations for Clinical Practice
Early initiation of rehabilitation in patients with
critical illness may have significant impact on
physical and functional outcomes in addition to
decreasing length of ICU stay and its associated
resource implications. Published accounts of critical
care rehabilitation report low frequencies of adverse
events suggesting that early physical activity is both
safe and feasible in this patient group following either
protocol driven or individualized recruitment proce-
dures. The potential for initiation of rehabilitation
activity should therefore be assessed immediately
upon ICU admission in all patients and continue
throughout the acute admission. Methods of increas-
ing the frequency of physiotherapy led rehabilitation
within critical care need to be reviewed with
particular attention to referral criteria for the
commencement of exercise. Specific interventions
which may preserve muscular performance (electrical
stimulation and active/passive cycling) should be
considered in patients who are otherwise unable to
perform active exercise for prolonged periods.
Evaluation of patient outcomes following critical
illness over and above survival alone has become an
important topic of critical care research. Future
studies should address questions in relation to the
56 Physical Therapy Reviews 2011 VOL . 16 NO .
type, dose, frequency, and duration of physical
activity strategies in large well defined cohorts of
critically ill patients with both short and protracted
ICU admission times. In particular, the relationship
between early rehabilitation and physical outcomes
within the ICU itself through ‘time to activity’
metrics, during ward based care and following
hospital discharge should be further explored using
validated functional outcome measures. Studies of
this nature will add to the emerging but small
evidence base guiding physiotherapy practice in this
area.
Acknowledgements
The authors give their kind thanks to Lesley Mill,
Clinical Lead Physiotherapist, Rehabilitation, The
Wellington Hospital (London, UK) for her com-
ments and editorial assistance in the preparation of
this review.
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