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Physiotherapists Role in ICU

Original Editor - Jaison Kiran Dsouza

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Introduction

Critical care involves the specialised treatment of patients whose conditions are life-threatening and who require comprehensive care and constant monitoring, typically provided in intensive care units (ICUs).[1]

Critically ill patients often experience long-term physical and psychological complications. Many are on long-term mechanical ventilation, leading to significant muscle weakness in approximately 25% of cases, while around 90% of long-term ICU survivors will experience ongoing muscle weakness.[2][3] Prolonged stays in the intensive care unit are also linked to impaired quality of life, functional decline, increased morbidity and mortality, higher costs of care, and extended lengths of hospital stay.[4]

Therefore, a multidisciplinary team is required in critical care, consisting of professionals uniquely qualified with the skills and expertise needed to assess and manage respiratory complications, physical deconditioning, and neuromuscular and musculoskeletal conditions.

Physiotherapy treatment, as part of a multidisciplinary approach to care, is integral in promoting lung function, reducing the incidence of ventilator-associated pneumonia, facilitating weaning, and promoting safe and early discharge from the intensive care unit.[5]

Physiotherapy Rehabilitation in ICU

Physiotherapy is a crucial intervention that prevents and mitigates the adverse effects of prolonged bed rest and mechanical ventilation during critical illness.[5] Rehabilitation delivered by physiotherapists is tailored to the individual needs of patients and depends on their level of consciousness, psychological status, and physical strength. This rehabilitation includes both active and passive therapies that promote movement, incorporating mobilisation techniques.[6] Early progressive physiotherapy, with a focus on mobility and walking while ventilated, is essential for minimising functional decline.[6] Yet in practice, rehabilitation in the ICU remains inconsistently applied. Studies measuring what actually happens in units around the world reveal significant differences in how and how often patients receive physiotherapy, with many hospitals yet to put evidence-based guidance into action.[7] Interestingly, a cross-sectional, multicentre point prevalence study examining the provision of mobility by physiotherapy or occupational therapy indicated a need for systematic and interdisciplinary mobilisation approaches for critically ill children, as therapists were not consistently consulted for mobilisation.[8]

Adverse effects of ICU stay:[9]

  • Physical Inactivity leading to muscular atrophy and generalised weakness
  • Diaphragmatic weakness due to prolonged mechanical ventilation
  • Pressure Ulcers
  • compromised cardiac and respiratory function
  • deep vein thrombosis
  • infections

Physiotherapist works to maintain and improve respiration and cardiac functions and later on aid in rehabilitation.

Short-term Goals:

  • Early activity: Both passive and active movement to maintain integrity of musculoskeletal system
  • Positioning patients: To allow gravity to help sputum drain from the lungs.
  • Manual techniques such as shaking and vibrations: These are applied to the ribs to try to loosen and clear the sputum.
  • Suction: By placing a small tube into the lungs to suck out the excess sputum.
  • They play a vital role in weaning a patient off ventilation.

Long-term Goals:

  • They plan an extensive rehabilitation programme to integrate and re-initiate the patient into society.
  • They set goals in conjunction with the medical team to rehabilitate the patient.

Rehabilitation goals are set in communication with the patient, patient's family and the medical team and are divided into short, medium or long term and change throughout the patient's recovery from critical illness. They can be physical as well as psychological but are concerned with the functional needs of the patient. Goals will need to be achievable and based on a regular patient assessment of physical and non-physical consequences of the critical illness throughout their recovery and change according to the progress.[10]

Physiotherapy Techniques in ICU

Respiratory Physiotherapy

The role of the respiratory physiotherapist is to assist in clearing the airways of the patients, and maintaining and improving the integrity of the respiratory system. Treatment interventions include:[11]

  • Positioning,
  • Education,
  • Manual and ventilator hyperinflation,
  • Weaning from mechanical ventilation,
  • Non-invasive ventilation,
  • Percussion, vibration, suctioning,
  • Respiratory muscle strengthening,
  • Breathing exercises and mobilisation

Rehabilitation

Early Mobilisation with a focus on returning to functional activities helps in reducing hospital stay and minimise functional decline.[12] Schaller et al.[13] conducted a randomised controlled trial in the ICU to determine the effectiveness of early goal orientation. They found it beneficial because it increased patient mobility after discharge and shortened the length of ICU stay. Compared with untreated patients, early mobilisation after cardiac surgery has been shown to reduce postoperative pain, shorten hospital stay, and increase functional capacity.[14]  A pilot RCT suggests early in-bed cycling with mechanically ventilated (MV) patients has positive outcomes.[15] A systematic review and meta-analysis suggest early rehabilitation in the ICU reduces the incidence of developing Intensive Care Unit Acquired weakness (ICUAW).[16]


The goals are mapped out based on patient's physical, psychological status. During his critical care unit stay, physiotherapists should perform a short clinical assessment:[17]

  • to determine the patient's risk of developing physical and non-physical morbidity.
  • to identify their current rehabilitation needs
  • For patients at risk, start rehabilitation as early as clinically possible which should include:[17]
  1. Measures to prevent avoidable physical and non-physical morbidity,
  2. Nutrition support
  3. An individualised, structured rehabilitation programme with frequent follow-up reviews. The details of the structured rehabilitation programme and the reviews should be collated and documented in the patient's clinical records.

Impact of Physiotherapy

Early intervention by physiotherapists in the ICU helps:

  • Reduce the patient's stay in the ICU and overall hospital stay.
  • Prevent ICU related complications
  • To improve function and quality of life in the long term

Studies have shown that physiotherapy intervention in critical care has helped reduce the mortality rate by 25%.[18] Results from a 2022 systematic review and meta-analysis of randomised controlled trials support the effectiveness of physical therapy in reducing chronic MV in acutely ill individuals without chronic respiratory disease.[19] A retrospective cohort study on 285 survivors of prolonged ICU-stay suggested that the ability to ambulate was associated with a higher possibility of being discharged, emphasising the importance of mobility training in long-term acute care hospitals.[20]

Resources

Physical Therapy Intervention in ICU

Physiotherapy in Intensive Care Unit

Exercise in Critical care

References

  1. ↑ Christensen M, Liang M. Critical care: A concept analysis. Int J Nurs Sci. 2023;10(3):403-413. Published 2023 Jun 24.
  2. ↑ Fleischmann-Struzek, C., Born, S., Kesselmeier, M., Ely, E. W., Töpfer, K., Romeike, H., Bauer, M., Bercker, S., Bodechtel, U., Fiedler, S., Groesdonk, H. V., Petros, S., Platzer, S., Rüddel, H., Schreiber, T., Reinhart, K., & Scherag, A. Functional dependence following intensive care unit-treated sepsis: three-year follow-up results from the prospective Mid-German sepsis cohort (MSC). Lancet Regional Health Eur. 2024;46:101066.
  3. ↑ Pierre, A., Favory, R., Bourel, C., Howsam, M., Romien, R., Lancel, S., & Preau, S. Muscle weakness after critical illness: unravelling biological mechanisms and clinical hurdles. Crit Care. 2025;29(1):248. Published 2025 Jun 17. doi:10.1186/s13054-025-05462-z
  4. ↑ Chartered Society of Physiotherapy, Physiotherapy works: critical care. Accessed on 2/6/19 http://www.csp.org.uk/publications/physiotherapy-works-critical-care
  5. ↑ 5.0 5.1 Lippi, L., de Sire, A., D'Abrosca, F., Polla, B., Marotta, N., Castello, L. M., Ammendolia, A., Molinari, C., & Invernizzi, M. Efficacy of Physiotherapy Interventions on Weaning in Mechanically Ventilated Critically Ill Patients: A Systematic Review and Meta-Analysis. Front Med (Lausanne). 2022;9:889218. Published 2022 May 9. doi:10.3389/fmed.2022.889218
  6. ↑ 6.0 6.1 Yang X, Zhang T, Cao L, Ye L, Song W. Early Mobilization for Critically Ill Patients. Respir Care. 2023;68(6):781-795.
  7. ↑ Hodgson, C. L., Ayre, E., Broadley, T., Burry, L., Casey, K., Dale, C., Eggmann, S., Freeman-Sanderson, A., Kho, M. E., Paton, M., Ridley, E. J., Rose, L., Schaller, S. J., & Herridge, M. S. Standard of care for rehabilitation in critical illness. Intensive Care Med. Published online April 30, 2026. doi:10.1007/s00134-026-08427-0
  8. ↑ Ista E, Scholefield BR, Manning JC, Harth I, Gawronski O, Bartkowska-Śniatkowska A, Ramelet AS, Kudchadkar SR. Mobilization practices in critically ill children: a European point prevalence study (EU PARK-PICU). Critical Care. 2020 Dec;24(1):1-1.
  9. ↑ Morgan A. Long-term outcomes from critical care. Surgery (Oxf). 2021;39(1):53-57.
  10. ↑ Rahimi RA, Skrzat J, Reddy DR, Zanni JM, Fan E, Stephens RS, Needham DM. Physical rehabilitation of patients in the intensive care unit requiring extracorporeal membrane oxygenation: a small case series. Physical therapy. 2013 Feb 1;93(2):248-55.
  11. ↑ Denehy L, Berney S. Physiotherapy in the intensive care unit. Physical Therapy Reviews. 2006;11(1):49.
  12. ↑ Rawal H, Bakhru RN. Early mobilization in the ICU. CHEST Critical Care. 2024 Mar 1;2(1)
  13. ↑ Schaller SJ, Anstey M, Blobner M, et al. Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial. Lancet. 2016;388(10052):1377-1388. doi:10.1016/S0140-6736(16)31637-3
  14. ↑ Ramos Dos Santos PM, Aquaroni Ricci N, Aparecida Bordignon Suster É, de Moraes Paisani D, Dias Chiavegato L Effects of early mobilisation in patients after cardiac surgery: a systematic review. Physiotherapy. 2017;103(1):1-12. doi:10.1016/j.physio.2016.08.003
  15. ↑ Kho ME, Molloy AJ, Clarke FJ, Ajami D, McCaughan M, Obrovac K, Murphy C, Camposilvan L, Herridge MS, Koo KK, Rudkowski J. TryCYCLE: a prospective study of the safety and feasibility of early in-bed cycling in mechanically ventilated patients. PloS one. 2016 Dec 28;11(12):e0167561.
  16. ↑ Anekwe DE, Biswas S, Bussières A, Spahija J. Early Rehabilitation Reduces the Likelihood of Developing Intensive Care Unit-Acquired Weakness: A Systematic Review and Meta-Analysis. Physiotherapy. 2019 Dec 19.
  17. ↑ 17.0 17.1 NICE clinical guideline 83 Developed by the Centre for Clinical Practice at NICE Rehabilitation after critical illness in adults Published date:  
  18. ↑ Tomasi CD, Figueiredo F, Constantino L, Grandi R, Topanotti MFL, Giombelli V, Dal-Pizzol F, Ritter C. Beneficial effect of respiratory physiotherapy in critically ill patients ventilated for more than 48 hours: A randomized controlled trial. Intensive Care Medicine. Conference 23rd Annual Congress of the European Society of Intensive Care Medicine, ESICM Barcelona Spain. Date of publication: September 2010.
  19. ↑ Lippi, L. et al. (2022) ‘Efficacy of physiotherapy interventions on weaning in mechanically ventilated critically ill patients: A systematic review and meta-analysis’, Frontiers in Medicine, 9. doi:10.3389/fmed.2022.889218.
  20. ↑ Tran DH, Maheshwari P, Nagaria Z, Patel HY, Verceles AC. Ambulatory Status Is Associated With Successful Discharge Home in Survivors of Critical Illness. Respiratory Care. 2020 Mar 31.
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