NICE GUIDELINE (2009) – Rehabilitation after critical illness
www.nice.org.uk/nicemedia/live/12137/43526/43526.pdf

ACPRC/BTS GUIDELINES (2009) – Physiotherapy management of the adult, medical, spontaneously breathing patient. Thorax, 64, suppl.i1-i52


Bailey P, Thomsen GE, Spuhler VJ et al (2007) Early activity is feasible and safe in respiratory failure patients. Crit Care Med, 35, 139-45.

Banasik J, Emerson R (2001) Effect of lateral positions on tissue oxygenation in the critically ill. Heart & Lung, 30, 4, 269-76
www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WG7-45SRHX3-1M&_coverDate=07%2F31%2F2001&_alid=469510701&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=6815&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=e60d5b3cd5f909bd7369ade3e60a9446
• lateral positioning of critically ill patients with hypoxemia or low cardiac output does not further endanger tissue oxygenation

Bell HJ, Ramsaroop DM, Duffin J (2003) The respiratory effects of two modes of passive exercise. Eur J Appl Physiol, 88, 544-2

Berney S, Denehy L (2003) The effect of physiotherapy treatment on oxygen consumption and haemodynamics in patients who are critically ill. Austr J Physiother, 49, 99-105
• sensible physiotherapy does not upset metabolic or haemodynamic variables (unlike Hammon 1992 which rubbished physiotherapy by using silly techniques on unstable patients who did not need physiotherapy)

Beuret P et al (2002) Prone position as prevention of lung injury in comatose patients. Int Care Med, 28, 564-9
• RCT demonstrating benefit of daily 4-hour proning for patients with GCS of 9 or less

Bird SJ (2002) Critical illness myopathy and polyneuropathy Curr Neurol Neuroscience Reports 2002, 2, 527-533
• critical illness polyneuropathy is seen in up to one third of septic patients
• critical illness myopathy associated with corticosteroids and/or neuromuscular blocking agents

Burtin C, Clerckx B, Robbeets C (2009) Early exercise in critically ill patients enhance short-term functional recovery. Crit Care Med, 37, 9, 2499-2505
• early exercise training leads to enhanced recovery of functional exercise capacity, self-perceived functional status and quadriceps force

Capuzzo M et al (2000) Validation of two quality of life questionnaires suitable for intensive care patients. Int Care Med, 26, 1296 - 1303
springerlink.metapress.com/app/home/contribution.asp?wasp=32a95183cc064cf5a2fe84917551307f&referrer=parent&backto=issue,23,48;journal,70,127;browsepublicationsresults,951,2443;

Chang A, Paratz J, Rollston J (2002) Ventilatory effects of neurophysiological facilitation and passive movement in patients with neurological injury. Austr J Physiother, 48, 305-9
ajp.physiotherapy.asn.au/AJP/vol_48/4/AustJPhysiotherv48i4Chang.pdf
• neurophysiological facilitation improves minute volume and SpO2 in neurological patients

Chiang LL, Wang LY, Wu CP, Wu HD, Wu YT (2006) Effects of physical training on functional status in patients with prolonged mechanical ventilation. Phys Ther, 86, 9 1271-1281
ptjournal.apta.org/content/86/9/1271.full
• 6-week physical training program may improve limb strength, ventilator-free time and functional outcomes

Clavet H, Hébert PC, Fergusson D (2008) Joint contracture following prolonged stay in the intensive care unit. Can Med Ass J, 178, 6, 691–7
www.ncbi.nlm.nih.gov/pmc/articles/PMC2263098/
• 39% of ICU patients staying for 2/52 or more acquired joint contractures, often in more than 1 joint; these were sufficient to impair function and persistent until discharge home

Clini E, Ambrosino N (2005) Early physiotherapy in the respiratory intensive care unit. Respir Med, 99 (9), 1096-1104.
• review of evidence-based effectiveness of weaning practices and physiotherapy treatment for patients with respiratory insufficiency in a RICU

Cohen D (1996) Modulating effects of propofol on metabolic and cardio-pulmonary responses to stressful ICU procedures. Crit Care Med, 24,612-17.
www.ccmjournal.com/pt/re/ccm/abstract.00003246-199604000-00011.htm;jsessionid=CmT0f6xyLmHY1j2xiNhQP5QhxiNJJJstZ9RLYmO4nu7NaWX5lvS0!654213914!-949856032!9001!-1
• propofol given 2 minutes before PT reduces the excess VO2 and VCO2 of treatment

Dingle M (2003) Role of dangling when moving from supine to standing position. Br J Nurs, 12, 346-50
• cardiovascular adjustments to standing from supine: physiology, risks, technique

Easby J (2003) Prone ventilation following witnessed pulmonary aspiration. Int Care Med, 29, 12, 2303-6
springerlink.metapress.com/(4nt0hn55kegoqri5o1po2rub)/app/home/contribution.asp?referrer=parent&backto=issue,30,42;journal,34,297;browsepublicationsresults,615,1574

Frank C, Akeson WH, Woo SLY, Amiel D (1994) Physiology and therapeutic value of passive joint motion. Clin Ortho Rel Res, 185, 113-24
• passive movements are required for sensory input, comfort, joint mobility, healing ability

Gosselink R, Bott J, Johnson M, et al (2008) Physiotherapy for adult patients with critical illness: recommendations of the ERS and European Society of Intensive Care Medicine task force on physiotherapy for critically ill patients. Int Care Med, 34, 7, 1188-99
springerlink.metapress.com/content/2r50121811p01215/fulltext.html
• evidence-based problems that respond to physiotherapy are: deconditioning, impaired airway clearance, atelectasis, intubation avoidance, and weaning failure

Graf J (2003) Health-related quality of life before, 1 month after, and 9 months after intensive care in medical patients. Crit Care Med, 31, 2163-9
www.ccmjournal.com/pt/re/ccm/abstract.00003246-200308000-00013.htm;jsessionid=B3cNfifXPxSZXhjggAnBZo1t0ci4C0e3oV0jwzuYnnwNcEXIYGOJ!113108930!-949856032!9001!-1
• useful outcome measures independent of severity of illness

Hicky J (2006) Manually ventilating & suctioning in-line with a SensorMedics 3100B high frequency oscillatory ventilator bench test. AARC Conference, Texas
www.cardinal.com/mps/focus/respiratory/abstracts/abstracts/ab2006/OF-06-157.asp
• method for manual hyperinflation and suction without losing airway pressure with HFO

Hiner C (2010) Clinicians’ perception of head-of-bed elevation. Am J Crit Care, 19, 2, 164-7
ajcc.aacnjournals.org/cgi/content/abstract/19/2/164
• between treatment sessions, the head of the bed should be elevated 30° to 45° to prevent ventilator-associated pneumonia.

Horiuchi K (1997) Insights into the increased oxygen demand during chest physiotherapy. Crit Care Med, 25, 1347-51
www.ccmjournal.com/pt/re/ccm/abstract.00003246-199708000-00022.htm;jsessionid=AjmBIL9a5V6zXdtfJ3MNV2pzP0UOdArwoWi6G5fC8ZyAEp0B8shL!1006468292!-949856032!9001!-1?index=1&results=1&count=10&searchid=1&nav=search
• increase in physiologic activity produced by chest physiotherapy is secondary to both exercise-like and stress-like responses

Ikeda S et al (2003) Repetitive stretch induces c-fos and myogenin mRNA within several hours in skeletal muscle removed from rats. Arch Phys Med Rehab, 84, 419-23
• mechanical repetitive stretch stimulates growth (in rats at least)

Jones AYM, Dean E (2004) Body position change and its effect on hemodynamic and metabolic status. Heart & Lung, 33, 5, 281-90
www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WG7-4DD8V6G-9&_user=4877861&_handle=V-WA-A-W-AE-MsSAYZW-UUW-U-AACVVAECWV-AACWUUUBWV-EDCBCDAZZ-AE-U&_fmt=full&_coverDate=10%2F31%2F2004&_rdoc=3&_orig=browse&_srch=%23toc%236815%232004%23999669994%23521198!&_cdi=6815&view=c&_acct=C000010278&_version=1&_urlVersion=0&_userid=4877861&md5=6493da12ba15c4c7ec9b18e4d215d3bb
• HR, BP, and VO2 highest in sitting compared with lying, and lowest in left-side-lying (in normals)

Kasper C (2002) Skeletal muscle damage and recovery. AACN Clinical Issues, 13, 3, 237-47
www.aacnclinicalissues.com/pt/re/aacn/abstract.00044067-200205000-00009.htm;jsessionid=FNqJLSGYf0h12XyM9tRv7LPshsP4CCsfgz4JWhgt9J18ZGzLfpTv!-1434154485!-949856145!8091!-1
• disuse atrophy of muscle begins within 4 hours of the start of bed rest; strenuous exercise of atrophic muscle can lead to muscle damage

Kemper (1992) The effect of increasing mechanical ventilation during physiotherapy. Respir Care, 37, 1313
• oxygen consumption increases by an average 40% during PT

Kortebein P (2009) Rehabilitation for hospital-associated deconditioning. Am J Phys Med Rehab. 88, 1, 66-77
journals.lww.com/ajpmr/toc/2009/01000
• deconditioning, even in younger patients, can have a prolonged effect on functional abilities
• for older patients, functional decline increases risk of institutionalisation and death
• inpatient rehabilitation is effective for improving function

Krause MW et al (2000) Postural drainage in intubated patients with acute lobar atelectasis. South African J Physiother, 56, 3, 29-32

Krishnagopalan S et al (2002) Body positioning of intensive care patients. Crit Care Med, 30(11), 2588-92
www.ccmjournal.com/pt/re/ccm/abstract.00003246-200211000-00031.htm;jsessionid=G6lMTf2GnX59gnJQTST6pXNpWWJpjyhjj3g46BCPl7p7LPyqD5bV!210985008!-949856144!8091!-1

Lewis M (2003) Intensive Care Unit rehabilitation within the UK. Physiotherapy, 89, 531-8
• rehab programmes in UK ICU’s

Lewis RM (2001) Airway clearance techniques for the patient with an artificial airway. Respir Care, 7, 808-817
www.rcjournal.com/contents/07.02/07.02.0808.asp
• literature review, with emphasis on infection control

Loram L, de Charmoy S (2002) The cardiopulmonary effect of passive movement. SA Journal Physiother, 58, 27-32
• positive effect of PMs on ventilation, PMs are OK with head injured patients

MacIntyre DL, Eng JJ, Allen TJ (2005) Recovery of lower limb function following 6 weeks of non-weight bearing. Acta Astronautica, 56, 792-800
• lack of stretch and muscle activity in immobile patients leads to shorter muscle fibres

McWilliams DJ, Atkinson D, Carter A, Foëx BA, Benington S, Conway DH (2009) Feasibility and impact of a structured, exercise-based rehabilitation programme for intensive care survivors. Physiother Theory Pract, 25, 8, 566-71
informahealthcare.com.ezproxy.brighton.ac.uk/doi/full/10.3109/09593980802668076

Nava S (1998) Rehabilitation of patients in a respiratory ICU. Arch.Phys.Med.Rehab, 79, 849-54
• early rehabilitation shows improved lung function, reduced SOB and increased exercise tolerance

Ntoumenopoulos G (2008) Mucus on the move: embed it or expel it--the patient, the clinician, and now the ventilator. Respir Care, 53, 10, 1276-9.

Patman S, Sanderson D and Blackmore M (2001) Physiotherapy following cardiac surgery: Is it necessary during the intubation period? Austr J Physiother, 47, 7-16
ptglobal.net/ajp/abst0101.html
• following routine, uncomplicated cardiac surgery, physiotherapy in the post-operative intubation period does not improve outcomes

Puckree T et al (2002) Does intercostal stretch alter breathing pattern and respiratory muscle activity in conscious adults? Physiotherapy, 88, 89-97
• intercostal stretch alters the pattern of breathing

Sciaky AJ (1994) Mobilizing the ITU patient. Phys Ther Pract, 3, 69-80.

Selsby D, Jones JG (1990) Some physiological and clinical aspects of chest physiotherapy. Br J Anaesth, 64, 621-31.

Skinner EH, Berney S, Warrillow S, Denehy L (2008) Rehabilitation and exercise prescription in Australian intensive care units. Physiotherapy, 94, 3, 220-29
www.sciencedirect.com/science?_ob=PublicationURL&_tockey=%23TOC%2318081%232008%23999059996%23695599%23FLA%23&_cdi=18081&_pubType=J&_auth=y&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c48ab21bdb0f076af332fb88ce4fdec7

Skirrow JC (2001) A randomized controlled trial of rehabilitation following critical illness. Int Care Med, 27, S241
• early rehab speeds recovery

Stiller K (2000) Physiotherapy in intensive care. Chest, 118, 1801-13
www.chestjournal.org/cgi/content/full/118/6/1801?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=Stiller+&andorexactfulltext=and&searchid=1126194233783_6358&stored_search=&FIRSTINDEX=0&sortspec=relevance&volume=118&firstpage=1801&resourcetype=1&journalcode=chest
• flawed references in this article lead to inaccurate conclusions about physiotherapy

Stiller K (2007) Safety issues that should be considered when mobilizing critically ill patients. Crit Care Clin, 23, 1, 35-53

Stockley RC, Hughes J, Morrison J, Rooney J (2010) An investigation of the use of passive movements in intensive care by UK physiotherapists. Physiotherapy, 96, 3, 228-33
• most physiotherapists do passive movements.

Stockton L (2009) Seating and pressure ulcers: clinical practice guideline. J Tissue Viability, 18, 4, 98-108
www.journaloftissueviability.com/article/S0965-206X%2809%2900036-9/abstract
• recommendations for seating, especially useful for patients needing prolonged sitting, e.g. spinal injury

Thelandersson A (2010) Cerebrovascular and systemic haemodynamic parameters during passive exercise. Adv Physiother, 12, 1, 58-63

Thomas PJ, Paratz JD, Lipman J (2007) Lateral positioning of ventilated intensive care patients: a study of oxygenation, respiratory mechanics, hemodynamics and adverse events. Heart Lung, 36, 4, 277-86

Thomas AJ, Wright K, Mill LM (2009) The incidence of physiotherapy and rehabilitation activities within a general intensive care unit. ACPRC Journal, 41, 3-8.

Topp R et al (2002) The effect of bed rest and potential of prehabilitation on patients in the intensive care unit. AACN Clin Issues, 13, 263-76
journals.lww.com/aacnadvancedcriticalcare/toc/2002/05000
• the case for prehabilitaion before admission to the ICU

Unoki T (2004) Effects of expiratory rib cage compression combined with endotracheal suctioning on gas exchange in mechanically ventilated rabbits with induced atelectasis. Resp Care, 49, 896-901
• rib cage compression probably exacerbates atelectasis

Van Duijnhoven NTL (2010) Resistive exercise versus resistive vibration exercise to counteract vascular adaptations to bed rest. J Appl Physiol, 108, 28-33
jap.physiology.org/content/108/1/28.full
• resistive vibration exercise shows a greater capacity to prevent the vascular effects of bed rest than resistive exercise

Weissman C, Kemper M (1991) The oxygen uptake-oxygen delivery relationship during ICU interventions. Chest, 99, 430-5.
www.chestjournal.org/cgi/content/abstract/99/2/430?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&searchid=1122372554207_1356&stored_search=&FIRSTINDEX=0&sortspec=relevance&volume=99&firstpage=430&journalcode=chest
• oxygen consumption increases by over 50% with ‘chest physical therapy’

Winkelman B, Higgins A, Chen K (2007) Cytokines in chronically ill patients after activity and rest. Biolog Res Nurs, 8, 261-271
• combined active and passive activity shows some benefit in reducing inflammation by restoring cytokine balance and in reducing length of stay

Wong WP, Paratz JD, Wilson K et al (2006) Hemodynamic and ventilatory effects of manual respiratory physiotherapy techniques of chest clapping, vibration, and shaking in an animal model. J Appl Physiol, 95, 991-8
• manual techniques do not usually cause significant haemodynamic effects

Zafiropoulos B, Alison JA, McCarren B (2004) Physiological responses to the early mobbilisation of the intubated, ventilated abdominal surgery patient. Austr J Physiother, 50, 95-100

Zanotti E (2003). Peripheral muscle strength training in bed-bound patients with COPD receiving mechanical ventilation; effect of electrical stimulation. Chest, 124, 292-96
www.chestjournal.org/cgi/content/full/124/1/292?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&volume=124&firstpage=292&resourcetype=HWCIT
• electrical stimulation to the limbs, added to active exercise, improves muscle strength and aids ability to transfer to a chair.



ACPRC = Association of Chartered Physiotherapists in Respiratory Care
HR = heart rate
GCS = Glasgow coma scale
PM = passive movement
PT = physiotherapy
RCT = randomized controlled trial
SpO2 = oxygen saturation by pulse oximetry
VO2 = oxygen consumption


(updated 30/11/10)