What is the recommended rehabilitation protocol for Intensive Care Unit (ICU) patients, including physiotherapy?

Rehabilitation Protocol and Physiotherapy for ICU Patients

Core Recommendation

Early mobilization ought to be started within the first few days in the ICU (within 72 hours of admission), depending on the patient's resilience and general condition. 1 This represents the highest-grade recommendation (Grade A) with high-quality evidence from the most recent 2023 Critical Care guidelines.

Initial Assessment Before Starting Rehabilitation

Before initiating any physiotherapy intervention, conduct a targeted assessment to determine:

• Underlying problems amenable to physiotherapy and which specific interventions are appropriate 1, 2
• Level of cooperation and neurological status to guide activity selection 2
• Hemodynamic stability - patients with hemodynamic instability or those requiring high FiO₂ and high ventilatory support are not candidates for aggressive mobilization 1
• Cardiorespiratory reserve, muscle strength, joint mobility, and functional status 2
• Appropriate monitoring of vital functions should be used throughout interventions to ensure both therapeutic benefit and safety 1

Progressive Mobilization Protocol

The rehabilitation approach follows a hierarchical progression based on patient tolerance 1:

Phase 1: Passive Interventions

• Positioning changes to increase gravitational stress through head tilt and positions approximating upright posture 1, 2
• Passive range of motion exercises 2
• Neuromuscular electrical stimulation (NMES) for patients unable to perform voluntary contractions 1
• Positioning, splinting, passive mobilization and muscle stretching to preserve joint mobility and skeletal muscle length 1

Phase 2: Assisted Exercises

• Bed cycling (ergometer training) can be considered as supplemental therapy in addition to early mobilization (Grade 0 recommendation, high-quality evidence) 1
• Functional exercises and resistance exercises 1
• Transfers from bed to chair 2

Phase 3: Active Exercises

• Active exercises and activities of daily living 1
• Standing with assistance using modified walking frames or tilt tables 1
• Walking with appropriate aids 2

Specific Exercise Prescription

Resistance Training

• Low-resistance multiple repetitions: 3 sets of 8-10 repetitions at 50-70% of 1 repetition maximum 1
• Strength training can be used as an adjunct to standard physical therapy to increase walking speed (Grade 0 recommendation, low-quality evidence) 1
• Perform daily within patient tolerance, commensurate with their goals 1

Aerobic Training

• Wheelchair cycle ergometer training can be used in addition to standard physical therapy to improve muscle strength and cardiovascular fitness (Grade 0 recommendation, low-quality evidence) 1
• For patients requiring long-term mechanical ventilation, a 6-week upper and lower limb training program improves limb muscle strength, increases ventilator-free time, and improves functional outcomes 1

Electrical Stimulation

• Electrical stimulation of the ventral thigh musculature can be used to strengthen muscles (Grade 0 recommendation) 1
• Daily NMES for at least 6 weeks has shown benefit in preventing disuse muscle atrophy 1

Safety Criteria and Contraindications

Patients NOT Suitable for Aggressive Mobilization:

• Hemodynamic instability 1
• High FiO₂ requirements 1
• High levels of ventilatory support 1

Risk Mitigation:

• Reduce metabolic demands by decreasing active muscle mass, exercise duration, or number of repetitions when needed 1
• Weigh the risk of moving a critically ill patient against the risks of immobility and recumbency 1
• Monitor for adverse events including arrhythmias, altered blood pressure, and desaturation during mobilization 3

Additional Rehabilitation Components

Respiratory Management

• Standardized assessment of swallowing function should be performed before oral nourishment is initiated, as dysphagia is frequent in patients with tracheostomy (Grade B recommendation, high-quality evidence) 1
• Inspiratory muscle training may improve respiratory muscle function 2

Psychological Support

• ICU diaries ought to be implemented for reducing risks of anxiety, depression, and PTSD after ICU discharge (Grade A recommendation) 1
• ICU diaries ought to be worked on with healthcare professionals in post-ICU care (Grade A recommendation) 1

Delirium Prevention

• Multimodal behavioral interventions ought to include sensory, cognitive, and emotional stimulation (mobilization, purposeful stimulation, aids for orientation, family contact) (Grade A recommendation) 1
• Interventions for stress reduction (pain, anxiety, sleep, noise), communication improvement, and family care should be applied (Grade B recommendation) 1

Common Pitfalls and Caveats

Critical Warning: A 2022 New England Journal of Medicine trial found that increased early active mobilization (mean 20.8 minutes daily vs 8.8 minutes usual care) did not improve days alive and out of hospital at 180 days, and was associated with increased adverse events (9.2% vs 4.1%, P=0.005) 3. This suggests that while early mobilization should be implemented, excessive intensity may be harmful. The key is structured, interprofessional implementation according to defined inclusion and exclusion criteria with appropriate dosage and frequency 1, not simply maximizing mobilization time.

Device-assisted therapy: While robot-assisted tilt tables, bed cycling, and gait training are increasingly used in clinical practice, current evidence does not support formal recommendations for device-assisted therapy 1. These can be considered as adjuncts but should not replace conventional physiotherapy.

Short-term vs long-term benefits: Early mobilization demonstrates clear short-term benefits (reduced mechanical ventilation duration, length of stay, delirium incidence, improved muscle strength at discharge) but does not significantly affect long-term physical, functional, cognitive, or psychosocial outcomes 1. However, the short-term benefits remain highly relevant for patients and families.