0
Original Research: Critical Care |

Physiotherapy in Intensive CarePhysiotherapy in Intensive Care: An Updated Systematic Review FREE TO VIEW

Kathy Stiller, PhD
Author and Funding Information

From the Physiotherapy Department, Royal Adelaide Hospital, Adelaide, SA, Australia.

Correspondence to: Kathy Stiller, PhD, Royal Adelaide Hospital, Physiotherapy Department, North Terrace, Adelaide, SA, Australia, 5000; e-mail: kathy.stiller@health.sa.gov.au


Funding/Support: The author has reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(3):825-847. doi:10.1378/chest.12-2930
Text Size: A A A
Published online

Background:  Although physiotherapy is frequently provided to patients in the ICU, its role has been questioned. The purpose of this systematic literature review, an update of one published in 2000, was to examine the evidence concerning the effectiveness of physiotherapy for adult, intubated patients who are mechanically ventilated in the ICU.

Methods:  The main literature search was undertaken on PubMed, with secondary searches of MEDLINE, CINAHL, Embase, the Cochrane Library, and the Physiotherapy Evidence Database. Only papers published from 1999 were included. No limitations were placed on study design, intervention type, or outcomes of clinical studies; nonsystematic reviews were excluded. Items were checked for relevance and data extracted from included studies. Marked heterogeneity of design precluded statistical pooling of results and led to a descriptive review.

Results:  Fifty-five clinical and 30 nonclinical studies were reviewed. The evidence from randomized controlled trials evaluating the effectiveness of routine multimodality respiratory physiotherapy is conflicting. Physiotherapy that comprises early progressive mobilization has been shown to be feasible and safe, with data from randomized controlled trials demonstrating that it can improve function and shorten ICU and hospital length of stay.

Conclusions:  Available new evidence, published since 1999, suggests that physiotherapy intervention that comprises early progressive mobilization is beneficial for adult patients in the ICU in terms of its positive effect on functional ability and its potential to reduce ICU and hospital length of stay. These new findings suggest that early progressive mobilization should be implemented as a matter of priority in all adult ICUs and an area of clinical focus for ICU physiotherapists.

Figures in this Article

In most developed countries, physiotherapy is seen as an integral component of the multidisciplinary management of patients in ICUs. The role of physiotherapy in the ICU and the treatment techniques used by physiotherapists in the ICU vary considerably between units, depending on factors such as the country in which the ICU is located, local tradition, staffing levels, and expertise. In 2000, Stiller1 published a literature review investigating the effectiveness of physiotherapy for adult, intubated patients on mechanical ventilation in the ICU, covering a broad range of physiotherapy practice. This concluded that there was only limited evidence concerning the effectiveness of physiotherapy in this setting and identified an urgent need for further research to be conducted to justify the role of physiotherapy in the ICU. The review is frequently cited in articles concerning the role of physiotherapy in the ICU. Given that > 10 years have passed since its publication, what new evidence regarding the role of physiotherapy in the ICU has emerged? Does this new evidence confirm the role of physiotherapy in the ICU? Does it highlight areas of clinical practice where physiotherapy is most effective?

The objective of this systematic review was to update a summary of the evidence concerning the effectiveness of physiotherapy in the ICU. In keeping with Stiller,1 this review only considers the management of adult, intubated patients on mechanical ventilation.

Search Strategy and Study Selection

The PICOS (population, intervention, comparison, outcome and study design) criteria used in this study were deliberately broad to capture all relevant articles, requiring only that the population comprised adult (aged ≥ 18 years), intubated, mechanically ventilated patients being cared for in an ICU setting and that a physiotherapy intervention had been evaluated or discussed. No limitations were placed on study outcomes. All relevant clinical articles were included and systematic literature reviews, expert opinion papers, and surveys were also eligible for inclusion. The primary literature search was conducted using the PubMed database for articles published from January 1, 1999, to July 31, 2012, using the following search terms: “intensive care” AND “physiotherapy.” Additional searches were undertaken on PubMed using the terms “critical care” or “intensive care” AND “physical therapy,” “therapeutic exercise,” “functional training,” “exercise,” “exercise therapy,” “mobilisation,” “rehabilitation” or “ambulation.” Secondary searches, using the same time limitations and search terms, were undertaken on MEDLINE, CINAHL, Embase, Cochrane Library, and the Physiotherapy Evidence Database. Titles and abstracts generated by the search strategy were assessed for eligibility and full-text copies of articles deemed to be potentially relevant were retrieved. Duplicate publications were excluded. If relevant articles could not be accessed via the Internet, authors were contacted directly. Given that this was a nonclinical study, institutional review board approval was not sought.

Methodological Quality and Analysis

The methodological quality of randomized controlled or comparative trials (RCTs) was appraised with reference to the National Health and Medical Research Council Guidelines2 and Consolidated Standards of Reporting Trials (CONSORT) statement.3 All data were extracted by the author. Marked heterogeneity of study design and outcome measures precluded statistical pooling of results for meta-analysis, hence a descriptive summary of the findings is presented.

Literature Search

The initial PubMed literature search identified 849 items published since 1999, with 50 relevant studies (34 clinical, 16 nonclinical) included in the review. An additional 35 relevant studies (21 clinical, 14 nonclinical) were retrieved in a broader PubMed search or from other databases. Thus, in total, 85 new studies (55 clinical, 30 nonclinical) were reviewed. Articles were most often excluded because they did not study the population and/or intervention of interest (Fig 1).

Figure Jump LinkFigure 1. Flowchart of selection of eligible studies.Grahic Jump Location
Systematic Reviews

Twelve systematic literature reviews were identified. Their characteristics, including a summary of their results and conclusions, are shown in Table 1.415 In contrast to the current review, which covers a wide range of ICU physiotherapy practices, these reviews focused on specific areas of physiotherapy practice in the ICU, with the most frequent topic being the early mobilization and rehabilitation of patients in the ICU.410 Despite only limited data being available, most concluded that early mobilization and rehabilitation are safe and effective in the ICU setting, although further research is required to confirm and extend its role.410

Table Graphic Jump Location
Table 1 —Characteristics of Systematic Literature Reviews

LOS = length of stay; MH = manual hyperinflation; OT = occupational therapy; PT = physiotherapy or physical therapy; Rx = treatment; VAP = ventilator-associated pneumonia.

a 

Indicates the number of articles in the reference list (number of studies included in review not specifically stated).

Clinical Trials: Study and Patient Characteristics

The clinical trials reviewed evaluated a variety of physiotherapy interventions, including multimodality respiratory physiotherapy, mobilization, inspiratory muscle training (IMT), and neuromuscular electrical stimulation (NMES). For the sake of clarity, study findings are presented according to the intervention evaluated.

Multimodality Respiratory Physiotherapy:

Eighteen clinical trials were identified that evaluated the effectiveness of multimodality respiratory physiotherapy, with the interventions studied including various combinations of positioning, manual hyperinflation (MH), ventilator hyperinflation (VH), chest wall vibrations, and rib-cage compression.1633 The characteristics and main findings of these 18 studies are shown in Table 2 (sorted according to methodological quality and sample size). There were five RCTs,1620 nine randomized crossover trials,2129 one systematically allocated controlled trial,30 one historical controlled trial,31 and two observational studies.32,33

Table Graphic Jump Location
Table 2 —Characteristics of Studies Evaluating Multimodality Respiratory Physiotherapy

ALI = acute lung injury; CPIS = clinical pulmonary infection score; CXR = chest radiograph; HR = heart rate; L = left; MAP = mean arterial BP; PEEP = positive end expiratory pressure; PEFR = peak expiratory flow rate; R = right; Svo2 = mixed venous oxygen saturation; V. co2 = CO2 output; VH = ventilator hyperinflation; Vt = tidal volume. See Table 1 legend for expansion of other abbreviations.

Four of the five RCTs were well designed and involved samples of at least 101 patients.1619 Study populations comprised patients who were intubated and mechanically ventilated after cardiac surgery,16 mechanically ventilated > 48 h,17,19 or mechanically ventilated with acquired brain injury.18 Patients were prospectively randomly allocated to a control group (usually receiving standard medical/nursing care) or a treatment group that received additional multimodality respiratory physiotherapy (comprising a combination of techniques such as positioning, MH, with or without chest wall vibrations). Frequency of this additional multimodality respiratory physiotherapy was as clinically indicated in two studies,16,17 bid,19 and six times a day.18 Medium-term clinical outcomes such as duration of intubation, incidence of ventilator-associated pneumonia (VAP), and length of stay (LOS) in the ICU and hospital were measured. Two of the four RCTs found no significant difference between groups for any outcomes,16,18 one found that the median time for 50% of patients to become ventilator-free was significantly longer in the treatment group,17 and the final study favored the treatment group, with significant benefits seen in terms of the clinical pulmonary infection score, ventilator weaning and mortality rates.19 The fifth RCT was methodologically compromised by a small sample size (n = 17) that was further compromised by division into three treatment groups.20

The nine randomized crossover trials all had comparatively small sample sizes (n ≤ 46) and prospectively evaluated the physiologic effects of individual respiratory physiotherapy interventions.2129 Six of the randomized crossover trials evaluated MH.21,2529 Three of these compared MH to VH, when added to a treatment of positioning and suction, with all finding that VH was as effective as MH for outcomes such as sputum clearance and respiratory compliance.21,26,29 Two studies investigated the addition of MH to a treatment of positioning and suction, with both finding that MH was associated with short-term beneficial physiologic effects such as improved respiratory compliance.27,28 Hodgson et al25 compared two different circuits for delivering MH, finding that while MH with a Mapleson C circuit cleared significantly more sputum than MH with a Laerdal circuit, this did not have any consequences in terms of oxygenation or respiratory compliance. Two randomized crossover trials evaluated the effect of expiratory rib-cage compression, finding that it did not add to the effectiveness of positioning and suction in terms of oxygenation, respiratory compliance, or sputum clearance.22,23 Finally, Berney et al,24 investigating 20 patients who were mechanically ventilated, found that the addition of a head-down tilt to MH, rather than flat side lying, increased the weight of sputum cleared.

A prospective, systematically allocated, controlled trial involving 60 patients who were mechanically ventilated was undertaken by Ntoumenopoulos et al.30 While the incidence of VAP was significantly lower in a group that received multimodality respiratory physiotherapy bid compared with a control group, duration of mechanical ventilation, ICU LOS and mortality were not significantly different between groups.

A large historical controlled trial by Malkoç et al31 (n = 501) found that a group that received multimodality respiratory physiotherapy had a significantly shorter duration of mechanical ventilation and ICU LOS than a historical control group. However, as the treatment group also received mobilization, it is not clear which components of therapy were effective.

From the two prospective observational studies, Thomas et al32 found that lateral positioning had no significant effect on oxygenation of 34 patients on mechanical ventilation and Clarke et al,33 studying 25 patients on mechanical ventilation, reported that manual hyperventilation can result in higher inflation pressures in patients with susceptible lungs.

Mobilization:

For the purposes of this review, the definition of mobilization provided by Stiller1 has been used, whereby mobilization is a broad term that encompasses active limb exercises, actively moving or turning in bed, sitting on the edge of the bed, sitting out of bed in a chair (via mechanical lifting machines, slide board, or standing transfer), standing, and walking. Twenty-six clinical trials were identified that evaluated the use of mobilization interventions.3459Table 3 summarizes their characteristics. There were three RCTs,3436 five nonrandomized controlled trials,3741 one historical controlled study,42 and 17 observational studies.4359

Table Graphic Jump Location
Table 3 —Characteristics of Studies Evaluating Mobilization

6MWD = 6-min walk distance; ADL = activities of daily living; BADL = basic activities of daily living; BBS = Berg Balance Scale; BI = Barthel Index; CBFV = cerebral blood flow velocity; CIX = cardiac index; CPP = cerebral perfusion pressure; DC = discharge; FIM = functional independence measure; ICP = intracranial pressure; O2ER = oxygen extraction ratio; PI = pulsatility index; ROM = range of motion; RR = respiratory rate; SF-36 = Medical Outcomes Study 36-Item Short Form Health Survey; Spo2 = percutaneous oxygen saturation; V. e = minute ventilation; V. o2 = oxygen consumption. See Table 1 and 2 legends for expansion of other abbreviations.

The largest prospective RCT, by Schweickert et al,34 involved 104 patients who had been mechanically ventilated for < 72 h and were likely to require ventilation for a further 24 h. The patients were randomly allocated to receive daily sedative interruption followed by therapy that concentrated on mobilization activities (eg, range of motion exercises, functional tasks, sit/stand/walk) or daily sedative interruption and standard medical/nursing care. Compared with the control group, the treatment group demonstrated a significantly shorter duration of delirium and mechanical ventilation, and significantly more patients in the treatment group achieved an independent functional status at hospital discharge. The second prospective RCT, involving 90 patients whose ICU LOS was anticipated as being > 7 days, investigated the effectiveness of adding cycling exercise using a bedside cycle ergometer to a standard physiotherapy mobilization regimen (ie, limb exercises, walk).35 While no significant differences were found between groups at ICU discharge, the treatment group achieved significantly higher distances in the 6-min walk test than the control group at hospital discharge and their quadriceps strength improved significantly between ICU and hospital discharge. The third RCT, by Chang et al,36 prospectively investigated the effect of sitting out of bed (for at least 30 min, most often on a daily basis) on the respiratory muscle strength of 34 patients over a 6-day study period. The patients in the control group were positioned supine or semirecumbent in bed. No significant differences were seen between groups.

Two of the five nonrandomized controlled studies prospectively allocated patients to a control group (standard medical/nursing care) or a treatment group (progressive mobilization [eg, limb exercises, sit/stand/walk]).37,41 Despite marked differences in sample size (n = 33037; n = 3241), both demonstrated advantages for the treatment group, including significantly better functional ability, which translated into benefits such as a significantly shorter ICU and hospital LOS. Two nonrandomized controlled studies prospectively compared a control phase, where patients received standard medical/nursing care, to a treatment phase following the introduction of a progressive mobilization program.39,40 Needham et al40 demonstrated benefits following implementation of the mobilization program (which included reduced sedation), including significantly better functional mobility in the ICU and significantly shorter ICU and hospital LOS. Similarly, Winkelman et al39 found that the ICU LOS was significantly shorter after implementation of a progressive mobilization program, although no significant difference was found for duration of mechanical ventilation. Yang et al38 found that progressive mobilization enhanced the success rate of ventilator weaning.

Bassett et al42 compared outcomes between a historical controlled group, where data were collated retrospectively, and a treatment group after the implementation of an early mobilization program across 13 ICUs. While details are scarce, no significant differences were seen between the two groups for outcomes such as the length of mechanical ventilation, and ICU and hospital LOS.

The 17 observational studies recorded outcomes regarding the feasibility, safety, and physiologic effects of mobilization on patients in the ICU.4359 Overall, mobilization activities were found to be feasible and safe, although associated at times with short-term changes in physiologic parameters, with the frequency of serious adverse events ≤ 1%. Garzon-Serrano et al47 prospectively compared the level of mobility achieved for 63 patients in the ICU according to whether mobilization was performed by nursing or physical therapy staff, finding that physical therapists mobilized patients to a significantly higher level than nursing staff. Barriers to the mobilization of patients in the ICU that were identified included the ICU culture,44 sedation,48 limited rehabilitation staffing,48 and patients being medically unfit.50 Skinner et al56 developed a clinical exercise outcome measure for use in the ICU, namely, the physical function ICU test (PFIT), finding it easy to use, responsive, and reliable in a study of 12 patients in the ICU.

Inspiratory Muscle Training:

Five clinical trials were found that evaluated the effectiveness of IMT in the ICU.6064 These studies are summarized in Table 4. There were two RCTs,60,61 two case series,62,63 and one single case report.64

Table Graphic Jump Location
Table 4 —Characteristics of Studies Evaluating Inspiratory Muscle Training, Neuromuscular Electrical Stimulation, and Other Interventions

APACHE 5 Acute Physiologic and Chronic Health Evaluation; IMT 5 inspiratory muscle training; MIP 5 maximal inspiratory pressure; MRC 5 Medical Research Council; NMES 5 neuromuscular electrical stimulation. See Table 13 legends for expansion of other abbreviations.

Cader et al,60 in a well-designed prospective RCT involving 41 elderly patients who were mechanically ventilated for > 48 h due to type 1 respiratory failure, found that daily progressive IMT using a threshold training device was associated with significant benefits (eg, shorter weaning time) compared with a control group. In contrast, the prospective RCT by Caruso et al,61 whose study sample comprised 25 patients likely to require mechanical ventilation > 72 h, found that IMT using the trigger sensitivity on the ventilator did not have significant benefits in terms of weaning duration or rate of reintubation.

Threshold IMT was found to be effective in terms of weaning ventilator-dependent patients in the case series by Sprague and Hopkins63 involving six patients, and a single case study by Bissett and Leditschke.64 Bissett et al,62 in another case series, evaluated the safety of IMT, with no deleterious effects on physiologic parameters or clinically important adverse effects recorded.

Neuromuscular Electrical Stimulation:

Three clinical studies, summarized in Table 4, were identified that evaluated the effectiveness of NMES.6567 There were two prospective, stratified RCTs65,66 and one within-subject RCT.67

The RCT by Routsi et al65 involved 52 critically ill patients, stratified according to age and sex, and evaluated the effect of daily NMES to the quadriceps and peroneous longus muscles. They demonstrated a significantly lower incidence of critical-illness polyneuromyopathy and reduced weaning time in the treatment group. The stratified RCT by Gruther et al66 allocated 33 patients to a daily session of NMES to the quadriceps muscle or a sham treatment, with the sample stratified according to ICU LOS. While no significant difference was seen between the treatment and sham groups for short-stay patients (< 7 days), longer-term patients (> 14 days) who received NMES had a significant increase in muscle thickness at 4 weeks, whereas the sham group had no significant change in muscle thickness. The within-subject RCT by Poulsen et al,67 involving eight male patients in the ICU with septic shock, found no significant difference in quadriceps muscle volume between patients’ control and treatment sides after 7 days.

Other Clinical Trials:

Three other clinical trials that investigated physiotherapy interventions in the ICU are summarized in Table 4.6870 Zeppos et al68 documented a low incidence of adverse physiologic effects associated with all physiotherapy interventions in the ICU; De Freitas69 found that patients who received physiotherapy were predominantly male, elderly, nonsurgical, and with high disease severity and mortality; and Clavet et al70 reported that patients with joint contractures in the ICU had a significantly longer ICU LOS and lower ambulatory level at the time of hospital discharge than those without joint contractures.

Nonclinical Studies: Study and Sample Characteristics
Expert Opinion:

Three articles, summarized in Table 5, provided expert opinions regarding the role of physiotherapy in the ICU.7173 Gosselink et al71 summarized the findings of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on the effectiveness of physiotherapy for acute and chronic critically ill patients. Despite noting a lack of high-level evidence, they identified the following evidence-based targets for physiotherapy: deconditioning, muscle weakness, joint stiffness, impaired airway clearance, atelectasis, intubation avoidance, and weaning failure. The two studies by Hanekom et al72,73 used a Delphi process to develop evidence-based clinical management algorithms for the prevention, identification, and management of pulmonary dysfunction in intubated patients in the ICU and for the early physical activity and mobilization of critically ill patients.

Table Graphic Jump Location
Table 5 —Characteristics of Nonclinical Studies

ERS = European Respiratory Society; ESICM = European Society of Intensive Care Medicine; NZ = New Zealand; UK = United Kingdom; US = United Statesct. See Table 14 legends for expansion of other abbreviations.

Surveys:

A total of 15 surveys (Table 5) were identified that evaluated physiotherapy interventions in the ICU.7488 Sample sizes ranged from 3288 to 482;74 most samples comprised physiotherapists alone,7476,7881,8486,88 two included physiotherapists and nursing staff,82,83 one study included ICU directors and physiotherapists,77 and the last included patients in the ICU.87 All studies used purpose-designed surveys. Topics surveyed were general physiotherapy service provision,74,79,80,82,85 use of passive movements,75,86 rehabilitation and exercise prescription,78 positioning,83 VH,76,84 MH,88 use of tilt tables,81 ICU directors’ perceptions of their physiotherapy service,77 and patient satisfaction with the ICU physiotherapy service.87 The findings of each study are summarized in Table 5.

This systematic review updates a summary of the research evidence concerning the effectiveness of physiotherapy in the ICU published in 2000. A total of 85 new studies (55 clinical and 30 nonclinical) were reviewed.

The most striking change in the evidence base since the review published by Stiller in 20001 has been the advent and growth of research, particularly in the last 5 years, evaluating the use of early progressive mobilization. In contrast to 2000, when no studies were identified, the current review included 26 clinical studies on this topic and, while study quality was variable, statistically significant and clinically important benefits resulting from early mobilization were demonstrated. These new clinical studies have shown that early progressive mobilization is feasible and safe, and results in significant functional benefits that may translate into positive effects on the ICU and hospital LOS. Stiller1 noted that the role of physiotherapy in the ICU would continue to be questioned until physiotherapy has been shown to have a favorable impact on broader outcomes of patients in the ICU. The new evidence demonstrating the beneficial effects of mobilization on broader outcomes such as the ICU and hospital LOS confirms an unquestionable role for physiotherapy in the ICU. Given that the demand for physiotherapy services often outstrips the resources available, and the new evidence demonstrating the effectiveness of physiotherapy interventions aimed at early mobilization, ICU physiotherapists should give priority to interventions aimed at early progressive mobilization. To be successful, implementation of early progressive mobilization relies on an ICU culture that considers mobilization an essential part of multidisciplinary care. Safety guidelines and protocols for progressive mobilization of patients in the ICU are available.34,37,42,47,89

Eighteen new clinical trials were identified that evaluated the effectiveness of multimodality respiratory physiotherapy for adult, intubated, mechanically ventilated patients in the ICU. The results of these trials support and extend the conclusions made by Stiller in 2000,1 namely, that multimodality respiratory physiotherapy may result in short-term improvements in pulmonary function. While there is some new evidence from RCTs that the provision of routine multimodality respiratory physiotherapy can impact positively on outcomes such as duration of intubation and the ICU LOS, there is, however, a similar amount of new high-quality evidence suggesting that it may not. In terms of specific respiratory physiotherapy interventions, there is limited evidence from new randomized crossover trials suggesting that expiratory rib-cage compression is ineffective and that MH may have beneficial short-term effects on respiratory compliance, concurring with the conclusions made in the 2000 review.1 New evidence has emerged demonstrating that VH is as effective as MH. There is new high-quality evidence concerning the effectiveness of IMT for patients in the ICU; however, this evidence is scarce, hence the routine or selective use of IMT for patients in the ICU cannot be recommended at present. Similarly, the evidence that has been published since 1999 concerning the effectiveness of NMES is limited and, thus, clinical recommendations regarding its use in ICU cannot be made.

Limitations of this systematic review included the variable methodological quality of the studies. The diverse range of study samples and study methodology precluded pooling of results and statistical analysis. The interventions that were provided usually comprised numerous components, making it impossible to determine the effectiveness of individual treatment components.

A strength of this literature review was the inclusion of all clinical studies that have evaluated physiotherapy for adult patients in the ICU, irrespective of study design. Additionally, by reviewing the evidence concerning a broad range of physiotherapy practice, rather than focusing on one specific type of intervention (eg, multimodality respiratory physiotherapy or mobilization alone), it has been possible to highlight the emerging evidence concerning the beneficial effects of early progressive mobilization compared with other physiotherapy interventions.

In summary, the evidence concerning the efficacy of routine multimodality respiratory physiotherapy for adult, intubated patients receiving mechanical ventilation remains unclear. There is strong, albeit limited, evidence published since the review in 2000 showing that physiotherapy intervention focusing on early progressive mobilization is feasible and safe, and results in significant functional benefits, which may translate into a reduced ICU and hospital LOS. This emerging evidence confirms the role of the physiotherapist in ICU and highlights that early progressive mobilization is an effective area of physiotherapy clinical practice for adult, intubated, mechanically ventilated patients. Further research to confirm the efficacy of early progressive mobilization is required, in particular to determine the optimal “dosage” in terms of its most effective components, intensity, duration, and frequency.

Author contributions: Dr Stiller had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Stiller: contributed to the literature search, identification of relevant studies, data extraction, analysis of the results, and writing of the paper.

Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: The author would like to thank Alisia Jedrzejczak, BPhysio (Hons), and Kate Roberts, BAppSc (Physio), BSc, for their helpful comments regarding this paper.

IMT

inspiratory muscle training

LOS

length of stay

MH

manual hyperinflation

NMES

neuromuscular electrical stimulation

RCT

randomized controlled/comparative trial

VAP

ventilator-associated pneumonia

VH

ventilator hyperinflation

Stiller K. Physiotherapy in intensive care: towards an evidence-based practice. Chest. 2000;118(6):1801-1813. [CrossRef] [PubMed]
 
National Health and Medical Research Council. How to use the evidence: assessment and application of scientific evidence. 2000. National Health and Medical Research Council. website. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp69.pdf. Accessed October 1, 2012.
 
Schulz KF, Altman DG, Moher D; CONSORT Group. CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials. Ann Intern Med. 2010;152(11):726-732. [CrossRef] [PubMed]
 
Adler J, Malone D. Early mobilization in the intensive care unit: a systematic review. Cardiopulm Phys Ther J. 2012;23(1):5-13. [PubMed]
 
Amidei C. Measurement of physiologic responses to mobilisation in critically ill adults. Intensive Crit Care Nurs. 2012;28(2):58-72. [CrossRef] [PubMed]
 
Amidei C. Mobilisation in critical care: a concept analysis. Intensive Crit Care Nurs. 2012;28(2):73-81. [CrossRef] [PubMed]
 
Choi J, Tasota FJ, Hoffman LA. Mobility interventions to improve outcomes in patients undergoing prolonged mechanical ventilation: a review of the literature. Biol Res Nurs. 2008;10(1):21-33. [CrossRef] [PubMed]
 
O’Connor ED, Walsham J. Should we mobilise critically ill patients? A review. Crit Care Resusc. 2009;11(4):290-300. [PubMed]
 
Thomas AJ. Exercise intervention in the critical care unit - what is the evidence? Phys Ther Rev. 2009;14(1):50-59. [CrossRef]
 
Thomas AJ. Physiotherapy led early rehabilitation of the patient with critical illness. Phys Ther Rev. 2011;16(1):46-57. [CrossRef]
 
Clini E, Ambrosino N. Early physiotherapy in the respiratory intensive care unit. Respir Med. 2005;99(9):1096-1104. [CrossRef] [PubMed]
 
Paulus F, Binnekade JM, Vroom MB, Schultz MJ. Benefits and risks of manual hyperinflation in intubated and mechanically ventilated intensive care unit patients: a systematic review. Crit Care. 2012;16(4):R145. [CrossRef] [PubMed]
 
Elliott D, Denehy L, Berney S, Alison JA. Assessing physical function and activity for survivors of a critical illness: a review of instruments. Aust Crit Care. 2011;24(3):155-166. [CrossRef] [PubMed]
 
Hanekom SD, Faure M, Coetzee A. Outcomes research in the ICU: an aid in defining the role of physiotherapy. Physiother Theory Pract. 2007;23(3):125-135. [CrossRef] [PubMed]
 
Hellweg S. Effectiveness of physiotherapy and occupational therapy after traumatic brain injury in the intensive care unit. Crit Care Res Pract. 2012;2012:768456. [PubMed]
 
Patman S, Sanderson D, Blackmore M. Physiotherapy following cardiac surgery: is it necessary during the intubation period? Aust J Physiother. 2001;47(1):7-16. [PubMed]
 
Templeton M, Palazzo MGA. Chest physiotherapy prolongs duration of ventilation in the critically ill ventilated for more than 48 hours. Intensive Care Med. 2007;33(11):1938-1945. [CrossRef] [PubMed]
 
Patman S, Jenkins S, Stiller K. Physiotherapy does not prevent, or hasten recovery from, ventilator-associated pneumonia in patients with acquired brain injury. Intensive Care Med. 2009;35(2):258-265. [CrossRef] [PubMed]
 
Pattanshetty RB, Gaude GS. Effect of multimodality chest physiotherapy in prevention of ventilator-associated pneumonia: A randomized clinical trial. Indian J Crit Care Med. 2010;14(2):70-76. [CrossRef] [PubMed]
 
Barker M, Adams S. An evaluation of a single chest physiotherapy treatment on mechanically ventilated patients with acute lung injury. Physiother Res Int. 2002;7(3):157-169. [CrossRef] [PubMed]
 
Dennis D, Jacob W, Budgeon C. Ventilator versus manual hyperinflation in clearing sputum in ventilated intensive care unit patients. Anaesth Intensive Care. 2012;40(1):142-149. [PubMed]
 
Unoki T, Kawasaki Y, Mizutani T, et al. Effects of expiratory rib-cage compression on oxygenation, ventilation, and airway-secretion removal in patients receiving mechanical ventilation. Respir Care. 2005;50(11):1430-1437. [PubMed]
 
Genc A, Akan M, Gunerli A. The effects of manual hyperinflation with or without rib-cage compression in mechanically ventilated patients. Ital J Physiother. 2011;1(2):48-54.
 
Berney S, Denehy L, Pretto J. Head-down tilt and manual hyperinflation enhance sputum clearance in patients who are intubated and ventilated. Aust J Physiother. 2004;50(1):9-14. [PubMed]
 
Hodgson C, Ntoumenopoulos G, Dawson H, Paratz J. The Mapleson C circuit clears more secretions than the Laerdal circuit during manual hyperinflation in mechanically-ventilated patients: a randomised cross-over trial. Aust J Physiother. 2007;53(1):33-38. [CrossRef] [PubMed]
 
Berney S, Denehy L. A comparison of the effects of manual and ventilator hyperinflation on static lung compliance and sputum production in intubated and ventilated intensive care patients. Physiother Res Int. 2002;7(2):100-108. [CrossRef] [PubMed]
 
Hodgson C, Denehy L, Ntoumenopoulos G, Santamaria J, Carroll S. An investigation of the early effects of manual lung hyperinflation in critically ill patients. Anaesth Intensive Care. 2000;28(3):255-261. [PubMed]
 
Choi JS-P, Jones AY-M. Effects of manual hyperinflation and suctioning in respiratory mechanics in mechanically ventilated patients with ventilator-associated pneumonia. Aust J Physiother. 2005;51(1):25-30. [CrossRef] [PubMed]
 
Savian C, Paratz J, Davies A. Comparison of the effectiveness of manual and ventilator hyperinflation at different levels of positive end-expiratory pressure in artificially ventilated and intubated intensive care patients. Heart Lung. 2006;35(5):334-341. [CrossRef] [PubMed]
 
Ntoumenopoulos G, Presneill JJ, McElholum M, Cade JF. Chest physiotherapy for the prevention of ventilator-associated pneumonia. Intensive Care Med. 2002;28(7):850-856. [CrossRef] [PubMed]
 
Malkoç M, Karadibak D, Yildirim Y. The effect of physiotherapy on ventilatory dependency and the length of stay in an intensive care unit. Int J Rehabil Res. 2009;32(1):85-88. [CrossRef] [PubMed]
 
Thomas PJ, Paratz JD, Lipman J, Stanton WR. Lateral positioning of ventilated intensive care patients: a study of oxygenation, respiratory mechanics, hemodynamics, and adverse events. Heart Lung. 2007;36(4):277-286. [CrossRef] [PubMed]
 
Clarke RCN, Kelly BE, Convery PN, Fee JPH. Ventilatory characteristics in mechanically ventilated patients during manual hyperventilation for chest physiotherapy. Anaesthesia. 1999;54(10):936-940. [CrossRef] [PubMed]
 
Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373(9678):1874-1882. [CrossRef] [PubMed]
 
Burtin C, Clerckx B, Robbeets C, et al. Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med. 2009;37(9):2499-2505. [CrossRef] [PubMed]
 
Chang M-Y, Chang L-Y, Huang Y-C, Lin K-M, Cheng C-H. Chair-sitting exercise intervention does not improve respiratory muscle function in mechanically ventilated intensive care unit patients. Respir Care. 2011;56(10):1533-1538. [CrossRef] [PubMed]
 
Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36(8):2238-2243. [CrossRef] [PubMed]
 
Yang P-H, Wang C-S, Wang Y-C, et al. Outcome of physical therapy intervention on ventilator weaning and functional status. Kaohsiung J Med Sci. 2010;26(7):366-372. [CrossRef] [PubMed]
 
Winkelman C, Johnson KD, Hejal R, et al. Examining the positive effects of exercise in intubated adults in ICU: a prospective repeated measures clinical study. Intensive Crit Care Nurs. 2012;28(6):307-318. [CrossRef] [PubMed]
 
Needham DM, Korupolu R, Zanni JM, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil. 2010;91(4):536-542. [CrossRef] [PubMed]
 
Chiang L-L, Wang L-Y, Wu C-P, Wu H-D, Wu Y-T. Effects of physical training on functional status in patients with prolonged mechanical ventilation. Phys Ther. 2006;86(9):1271-1281. [CrossRef] [PubMed]
 
Bassett RD, Vollman KM, Brandwene L, Murray T. Integrating a multidisciplinary mobility programme into intensive care practice (IMMPTP): a multicentre collaborative. Intensive Crit Care Nurs. 2012;28(2):88-97. [CrossRef] [PubMed]
 
Leditschke IA, Green M, Irvine J, Bissett B, Mitchell IA. What are the barriers to mobilizing intensive care patients? Cardiopulm Phys Ther J. 2012;23(1):26-29. [PubMed]
 
Thomsen GE, Snow GL, Rodriguez L, Hopkins RO. Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority. Crit Care Med. 2008;36(4):1119-1124. [CrossRef] [PubMed]
 
Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007;35(1):139-145. [CrossRef] [PubMed]
 
Clini EM, Crisafulli E, Antoni FD, et al. Functional recovery following physical training in tracheotomized and chronically ventilated patients. Respir Care. 2011;56(3):306-313. [CrossRef] [PubMed]
 
Garzon-Serrano J, Ryan C, Waak K, et al. Early mobilization in critically ill patients: patients’ mobilization level depends on health care provider’s profession. PM R. 2011;3(4):307-313. [CrossRef] [PubMed]
 
Zanni JM, Korupolu R, Fan E, et al. Rehabilitation therapy and outcomes in acute respiratory failure: an observational pilot project. J Crit Care. 2010;25(2):254-262. [CrossRef] [PubMed]
 
Stiller K, Phillips AC, Lambert P. The safety of mobilisation and its effect on haemodynamic and respiratory status of intensive care patients. Physiother Theory Pract. 2004;20(3):175-185. [CrossRef]
 
Bahadur K, Jones G, Ntoumenopoulos G. An observational study of sitting out of bed in tracheostomised patients in the intensive care unit. Physiother. 2008;94(4):300-305. [CrossRef]
 
Bourdin G, Barbier J, Burle J-F, et al. The feasibility of early physical activity in intensive care unit patients: a prospective observational one-center study. Respir Care. 2010;55(4):400-407. [PubMed]
 
Nordon-Craft A, Schenkman M, Ridgeway K, Benson A, Moss M. Physical therapy management and patient outcomes following ICU-acquired weakness: a case series. J Neurol Phys Ther. 2011;35(3):133-140. [CrossRef] [PubMed]
 
Norrenberg M, De Backer D, Freidman G, Moraine J-J, Vincent J-L. Cardiovascular response to passive leg movement in critically ill patients. Clin Intensive Care. 1999;10(1):1-6.
 
Chang AT, Boots RJ, Hodges PW, Thomas PJ, Paratz JD. Standing with the assistance of a tilt table improves minute ventilation in chronic critically ill patients. Arch Phys Med Rehabil. 2004;85(12):1972-1976. [CrossRef] [PubMed]
 
Zafiropoulos B, Alison JA, McCarren B. Physiological responses to the early mobilisation of the intubated, ventilated abdominal surgery patient. Aust J Physiother. 2004;50(2):95-100. [PubMed]
 
Skinner EH, Berney S, Warrillow S, Denehy L. Development of a physical function outcome measure (PFIT) and a pilot exercise training protocol for use in intensive care. Crit Care Resusc. 2009;11(2):110-115. [PubMed]
 
Thelandersson A, Cider A, Volkmann R. Cerebrovascular and systemic haemodynamic parameters during passive exercise. Advances in Physiotherapy. 2010;12(1):58-63. [CrossRef]
 
Thelandersson A, Volkmann R, Cider A. Blood flow velocity and vascular resistance during passive leg exercise in the critically ill patient. Clin Physiol Funct Imaging. 2012;32(5):338-342. [CrossRef] [PubMed]
 
Hashim AM, Joseph LH, Embong J, Kasim Z, Mohan V. Tilt table practice improved ventilation in a patient with prolonged artificial ventilation support in intensive care unit. Iran J Med Sci. 2012;37(1):54-57. [PubMed]
 
Cader SA, Vale RG, Castro JC, et al. Inspiratory muscle training improves maximal inspiratory pressure and may assist weaning in older intubated patients: a randomised trial. J Physiother. 2010;56(3):171-177. [CrossRef] [PubMed]
 
Caruso P, Denari SDC, Ruiz SAL, et al. Inspiratory muscle training is ineffective in mechanically ventilated critically ill patients. Clinics (Sao Paulo). 2005;60(6):479-484. [CrossRef] [PubMed]
 
Bissett B, Leditschke IA, Green M. Specific inspiratory muscle training is safe in selected patients who are ventilator-dependent: a case series. Intensive Crit Care Nurs. 2012;28(2):98-104. [CrossRef] [PubMed]
 
Sprague SS, Hopkins PD. Use of inspiratory strength training to wean six patients who were ventilator-dependent. Phys Ther. 2003;83(2):171-181. [PubMed]
 
Bissett B, Leditschke IA. Inspiratory muscle training to enhance weaning from mechanical ventilation. Anaesth Intensive Care. 2007;35(5):776-779. [PubMed]
 
Routsi C, Gerovasili V, Vasileiadis I, et al. Electrical muscle stimulation prevents critical illness polyneuromyopathy: a randomized parallel intervention trial. Crit Care. 2010;14(2):R74. [CrossRef] [PubMed]
 
Gruther W, Kainberger F, Fialka-Moser V, et al. Effects of neuromuscular electrical stimulation on muscle layer thickness of knee extensor muscles in intensive care unit patients: a pilot study. J Rehabil Med. 2010;42(6):593-597. [CrossRef] [PubMed]
 
Poulsen JB, Møller K, Jensen CV, Weisdorf S, Kehlet H, Perner A. Effect of transcutaneous electrical muscle stimulation on muscle volume in patients with septic shock. Crit Care Med. 2011;39(3):456-461. [CrossRef] [PubMed]
 
Zeppos L, Patman S, Berney S, Adsett JA, Bridson JM, Paratz JD. Physiotherapy in intensive care is safe: an observational study. Aust J Physiother. 2007;53(4):279-283. [CrossRef] [PubMed]
 
De Freitas ERFS. Profile and severity of the patients of intensive care units: prospective application of the APACHE II index. Rev Lat Am Enfermagem. 2010;18(3):317-323. [CrossRef] [PubMed]
 
Clavet H, Hébert PC, Fergusson DA, Doucette S, Trudel G. Joint contractures in the intensive care unit: association with resource utilization and ambulatory status at discharge. Disabil Rehabil. 2011;33(2):105-112. [CrossRef] [PubMed]
 
Gosselink R, Bott J, Johnson M, et al. Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on physiotherapy for critically ill patients. Intensive Care Med. 2008;34(7):1188-1199. [CrossRef] [PubMed]
 
Hanekom S, Berney S, Morrow B, et al. The validation of a clinical algorithm for the prevention and management of pulmonary dysfunction in intubated adults—a synthesis of evidence and expert opinion. J Eval Clin Pract. 2011;17(4):801-810. [CrossRef] [PubMed]
 
Hanekom S, Gosselink R, Dean E, et al. The development of a clinical management algorithm for early physical activity and mobilization of critically ill patients: synthesis of evidence and expert opinion and its translation into practice. Clin Rehabil. 2011;25(9):771-787. [CrossRef] [PubMed]
 
Hodgin KE, Nordon-Craft A, McFann KK, Mealer ML, Moss M. Physical therapy utilization in intensive care units: results from a national survey. Crit Care Med. 2009;37(2):561-566. [CrossRef] [PubMed]
 
Stockley RC, Hughes J, Morrison J, Rooney J. An investigation of the use of passive movements in intensive care by UK physiotherapists. Physiotherapy. 2010;96(3):228-233. [CrossRef] [PubMed]
 
Hayes K, Seller D, Webb M, Hodgson CL, Holland AE. Ventilator hyperinflation: a survey of current physiotherapy practice in Australia and New Zealand. New Zealand Journal of Physiotherapy. 2011;39(3):124-130.
 
Jones AY-M. Intensive care physiotherapy–medical staff perceptions. Hong Kong Physiotherapy Journal. 2001;19(1):9-16. [CrossRef]
 
Skinner EH, Berney S, Warrillow S, Denehy L. Rehabilitation and exercise prescription in Australian intensive care units. Physiother. 2008;94(3):220-229. [CrossRef]
 
Norrenberg M, Vincent J-L; European Society of Intensive Care Medicine. A profile of European intensive care unit physiotherapists. Intensive Care Med. 2000;26(7):988-994. [CrossRef] [PubMed]
 
Kumar JA, Maiya AG, Pereira D. Role of physiotherapists in intensive care units of India: a multicenter survey. Indian J Crit Care Med. 2007;11(4):198-203. [CrossRef]
 
Chang AT, Boots R, Hodges PW, Paratz J. Standing with assistance of a tilt table in intensive care: a survey of Australian physiotherapy practice. Aust J Physiother. 2004;50(1):51-54. [PubMed]
 
Chaboyer W, Gass E, Foster M. Patterns of chest physiotherapy in Australian intensive care units. J Crit Care. 2004;19(3):145-151. [CrossRef] [PubMed]
 
Thomas PJ, Paratz JD, Stanton WR, Deans R, Lipman J. Positioning practices for ventilated intensive care patients: current practice, indications and contraindications. Aust Crit Care. 2006;19(4):122-126., 128, 130-132. [CrossRef] [PubMed]
 
Dennis DM, Jacob WJ, Samuel FD. A survey of the use of ventilator hyperinflation in Australian tertiary intensive care units. Crit Care Resusc. 2010;12(4):262-268. [PubMed]
 
Matilainen T, Olseni L. Physiotherapists in general intensive care units in Sweden–professional role, educational preferences and opinion about specialist certification. Nordisk Fysioterapi. 2005;9(2):74-81.
 
Wiles L, Stiller K. Passive limb movements for patients in an intensive care unit: a survey of physiotherapy practice in Australia. J Crit Care. 2010;25(3):501-508. [CrossRef] [PubMed]
 
Stiller K, Wiles L. Patient satisfaction with the physiotherapy service in an intensive care unit. South African Journal of Physiotherapy. 2008;64(1):1-5.
 
Hodgson C, Carroll S, Denehy L. A survey of manual hyperinflation in Australian hospitals. Aust J Physiother. 1999;45(3):185-193. [PubMed]
 
Stiller K. Safety issues that should be considered when mobilizing critically ill patients. Crit Care Clin. 2007;23(1):35-53. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. Flowchart of selection of eligible studies.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Characteristics of Systematic Literature Reviews

LOS = length of stay; MH = manual hyperinflation; OT = occupational therapy; PT = physiotherapy or physical therapy; Rx = treatment; VAP = ventilator-associated pneumonia.

a 

Indicates the number of articles in the reference list (number of studies included in review not specifically stated).

Table Graphic Jump Location
Table 2 —Characteristics of Studies Evaluating Multimodality Respiratory Physiotherapy

ALI = acute lung injury; CPIS = clinical pulmonary infection score; CXR = chest radiograph; HR = heart rate; L = left; MAP = mean arterial BP; PEEP = positive end expiratory pressure; PEFR = peak expiratory flow rate; R = right; Svo2 = mixed venous oxygen saturation; V. co2 = CO2 output; VH = ventilator hyperinflation; Vt = tidal volume. See Table 1 legend for expansion of other abbreviations.

Table Graphic Jump Location
Table 3 —Characteristics of Studies Evaluating Mobilization

6MWD = 6-min walk distance; ADL = activities of daily living; BADL = basic activities of daily living; BBS = Berg Balance Scale; BI = Barthel Index; CBFV = cerebral blood flow velocity; CIX = cardiac index; CPP = cerebral perfusion pressure; DC = discharge; FIM = functional independence measure; ICP = intracranial pressure; O2ER = oxygen extraction ratio; PI = pulsatility index; ROM = range of motion; RR = respiratory rate; SF-36 = Medical Outcomes Study 36-Item Short Form Health Survey; Spo2 = percutaneous oxygen saturation; V. e = minute ventilation; V. o2 = oxygen consumption. See Table 1 and 2 legends for expansion of other abbreviations.

Table Graphic Jump Location
Table 4 —Characteristics of Studies Evaluating Inspiratory Muscle Training, Neuromuscular Electrical Stimulation, and Other Interventions

APACHE 5 Acute Physiologic and Chronic Health Evaluation; IMT 5 inspiratory muscle training; MIP 5 maximal inspiratory pressure; MRC 5 Medical Research Council; NMES 5 neuromuscular electrical stimulation. See Table 13 legends for expansion of other abbreviations.

Table Graphic Jump Location
Table 5 —Characteristics of Nonclinical Studies

ERS = European Respiratory Society; ESICM = European Society of Intensive Care Medicine; NZ = New Zealand; UK = United Kingdom; US = United Statesct. See Table 14 legends for expansion of other abbreviations.

References

Stiller K. Physiotherapy in intensive care: towards an evidence-based practice. Chest. 2000;118(6):1801-1813. [CrossRef] [PubMed]
 
National Health and Medical Research Council. How to use the evidence: assessment and application of scientific evidence. 2000. National Health and Medical Research Council. website. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp69.pdf. Accessed October 1, 2012.
 
Schulz KF, Altman DG, Moher D; CONSORT Group. CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials. Ann Intern Med. 2010;152(11):726-732. [CrossRef] [PubMed]
 
Adler J, Malone D. Early mobilization in the intensive care unit: a systematic review. Cardiopulm Phys Ther J. 2012;23(1):5-13. [PubMed]
 
Amidei C. Measurement of physiologic responses to mobilisation in critically ill adults. Intensive Crit Care Nurs. 2012;28(2):58-72. [CrossRef] [PubMed]
 
Amidei C. Mobilisation in critical care: a concept analysis. Intensive Crit Care Nurs. 2012;28(2):73-81. [CrossRef] [PubMed]
 
Choi J, Tasota FJ, Hoffman LA. Mobility interventions to improve outcomes in patients undergoing prolonged mechanical ventilation: a review of the literature. Biol Res Nurs. 2008;10(1):21-33. [CrossRef] [PubMed]
 
O’Connor ED, Walsham J. Should we mobilise critically ill patients? A review. Crit Care Resusc. 2009;11(4):290-300. [PubMed]
 
Thomas AJ. Exercise intervention in the critical care unit - what is the evidence? Phys Ther Rev. 2009;14(1):50-59. [CrossRef]
 
Thomas AJ. Physiotherapy led early rehabilitation of the patient with critical illness. Phys Ther Rev. 2011;16(1):46-57. [CrossRef]
 
Clini E, Ambrosino N. Early physiotherapy in the respiratory intensive care unit. Respir Med. 2005;99(9):1096-1104. [CrossRef] [PubMed]
 
Paulus F, Binnekade JM, Vroom MB, Schultz MJ. Benefits and risks of manual hyperinflation in intubated and mechanically ventilated intensive care unit patients: a systematic review. Crit Care. 2012;16(4):R145. [CrossRef] [PubMed]
 
Elliott D, Denehy L, Berney S, Alison JA. Assessing physical function and activity for survivors of a critical illness: a review of instruments. Aust Crit Care. 2011;24(3):155-166. [CrossRef] [PubMed]
 
Hanekom SD, Faure M, Coetzee A. Outcomes research in the ICU: an aid in defining the role of physiotherapy. Physiother Theory Pract. 2007;23(3):125-135. [CrossRef] [PubMed]
 
Hellweg S. Effectiveness of physiotherapy and occupational therapy after traumatic brain injury in the intensive care unit. Crit Care Res Pract. 2012;2012:768456. [PubMed]
 
Patman S, Sanderson D, Blackmore M. Physiotherapy following cardiac surgery: is it necessary during the intubation period? Aust J Physiother. 2001;47(1):7-16. [PubMed]
 
Templeton M, Palazzo MGA. Chest physiotherapy prolongs duration of ventilation in the critically ill ventilated for more than 48 hours. Intensive Care Med. 2007;33(11):1938-1945. [CrossRef] [PubMed]
 
Patman S, Jenkins S, Stiller K. Physiotherapy does not prevent, or hasten recovery from, ventilator-associated pneumonia in patients with acquired brain injury. Intensive Care Med. 2009;35(2):258-265. [CrossRef] [PubMed]
 
Pattanshetty RB, Gaude GS. Effect of multimodality chest physiotherapy in prevention of ventilator-associated pneumonia: A randomized clinical trial. Indian J Crit Care Med. 2010;14(2):70-76. [CrossRef] [PubMed]
 
Barker M, Adams S. An evaluation of a single chest physiotherapy treatment on mechanically ventilated patients with acute lung injury. Physiother Res Int. 2002;7(3):157-169. [CrossRef] [PubMed]
 
Dennis D, Jacob W, Budgeon C. Ventilator versus manual hyperinflation in clearing sputum in ventilated intensive care unit patients. Anaesth Intensive Care. 2012;40(1):142-149. [PubMed]
 
Unoki T, Kawasaki Y, Mizutani T, et al. Effects of expiratory rib-cage compression on oxygenation, ventilation, and airway-secretion removal in patients receiving mechanical ventilation. Respir Care. 2005;50(11):1430-1437. [PubMed]
 
Genc A, Akan M, Gunerli A. The effects of manual hyperinflation with or without rib-cage compression in mechanically ventilated patients. Ital J Physiother. 2011;1(2):48-54.
 
Berney S, Denehy L, Pretto J. Head-down tilt and manual hyperinflation enhance sputum clearance in patients who are intubated and ventilated. Aust J Physiother. 2004;50(1):9-14. [PubMed]
 
Hodgson C, Ntoumenopoulos G, Dawson H, Paratz J. The Mapleson C circuit clears more secretions than the Laerdal circuit during manual hyperinflation in mechanically-ventilated patients: a randomised cross-over trial. Aust J Physiother. 2007;53(1):33-38. [CrossRef] [PubMed]
 
Berney S, Denehy L. A comparison of the effects of manual and ventilator hyperinflation on static lung compliance and sputum production in intubated and ventilated intensive care patients. Physiother Res Int. 2002;7(2):100-108. [CrossRef] [PubMed]
 
Hodgson C, Denehy L, Ntoumenopoulos G, Santamaria J, Carroll S. An investigation of the early effects of manual lung hyperinflation in critically ill patients. Anaesth Intensive Care. 2000;28(3):255-261. [PubMed]
 
Choi JS-P, Jones AY-M. Effects of manual hyperinflation and suctioning in respiratory mechanics in mechanically ventilated patients with ventilator-associated pneumonia. Aust J Physiother. 2005;51(1):25-30. [CrossRef] [PubMed]
 
Savian C, Paratz J, Davies A. Comparison of the effectiveness of manual and ventilator hyperinflation at different levels of positive end-expiratory pressure in artificially ventilated and intubated intensive care patients. Heart Lung. 2006;35(5):334-341. [CrossRef] [PubMed]
 
Ntoumenopoulos G, Presneill JJ, McElholum M, Cade JF. Chest physiotherapy for the prevention of ventilator-associated pneumonia. Intensive Care Med. 2002;28(7):850-856. [CrossRef] [PubMed]
 
Malkoç M, Karadibak D, Yildirim Y. The effect of physiotherapy on ventilatory dependency and the length of stay in an intensive care unit. Int J Rehabil Res. 2009;32(1):85-88. [CrossRef] [PubMed]
 
Thomas PJ, Paratz JD, Lipman J, Stanton WR. Lateral positioning of ventilated intensive care patients: a study of oxygenation, respiratory mechanics, hemodynamics, and adverse events. Heart Lung. 2007;36(4):277-286. [CrossRef] [PubMed]
 
Clarke RCN, Kelly BE, Convery PN, Fee JPH. Ventilatory characteristics in mechanically ventilated patients during manual hyperventilation for chest physiotherapy. Anaesthesia. 1999;54(10):936-940. [CrossRef] [PubMed]
 
Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373(9678):1874-1882. [CrossRef] [PubMed]
 
Burtin C, Clerckx B, Robbeets C, et al. Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med. 2009;37(9):2499-2505. [CrossRef] [PubMed]
 
Chang M-Y, Chang L-Y, Huang Y-C, Lin K-M, Cheng C-H. Chair-sitting exercise intervention does not improve respiratory muscle function in mechanically ventilated intensive care unit patients. Respir Care. 2011;56(10):1533-1538. [CrossRef] [PubMed]
 
Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36(8):2238-2243. [CrossRef] [PubMed]
 
Yang P-H, Wang C-S, Wang Y-C, et al. Outcome of physical therapy intervention on ventilator weaning and functional status. Kaohsiung J Med Sci. 2010;26(7):366-372. [CrossRef] [PubMed]
 
Winkelman C, Johnson KD, Hejal R, et al. Examining the positive effects of exercise in intubated adults in ICU: a prospective repeated measures clinical study. Intensive Crit Care Nurs. 2012;28(6):307-318. [CrossRef] [PubMed]
 
Needham DM, Korupolu R, Zanni JM, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil. 2010;91(4):536-542. [CrossRef] [PubMed]
 
Chiang L-L, Wang L-Y, Wu C-P, Wu H-D, Wu Y-T. Effects of physical training on functional status in patients with prolonged mechanical ventilation. Phys Ther. 2006;86(9):1271-1281. [CrossRef] [PubMed]
 
Bassett RD, Vollman KM, Brandwene L, Murray T. Integrating a multidisciplinary mobility programme into intensive care practice (IMMPTP): a multicentre collaborative. Intensive Crit Care Nurs. 2012;28(2):88-97. [CrossRef] [PubMed]
 
Leditschke IA, Green M, Irvine J, Bissett B, Mitchell IA. What are the barriers to mobilizing intensive care patients? Cardiopulm Phys Ther J. 2012;23(1):26-29. [PubMed]
 
Thomsen GE, Snow GL, Rodriguez L, Hopkins RO. Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority. Crit Care Med. 2008;36(4):1119-1124. [CrossRef] [PubMed]
 
Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007;35(1):139-145. [CrossRef] [PubMed]
 
Clini EM, Crisafulli E, Antoni FD, et al. Functional recovery following physical training in tracheotomized and chronically ventilated patients. Respir Care. 2011;56(3):306-313. [CrossRef] [PubMed]
 
Garzon-Serrano J, Ryan C, Waak K, et al. Early mobilization in critically ill patients: patients’ mobilization level depends on health care provider’s profession. PM R. 2011;3(4):307-313. [CrossRef] [PubMed]
 
Zanni JM, Korupolu R, Fan E, et al. Rehabilitation therapy and outcomes in acute respiratory failure: an observational pilot project. J Crit Care. 2010;25(2):254-262. [CrossRef] [PubMed]
 
Stiller K, Phillips AC, Lambert P. The safety of mobilisation and its effect on haemodynamic and respiratory status of intensive care patients. Physiother Theory Pract. 2004;20(3):175-185. [CrossRef]
 
Bahadur K, Jones G, Ntoumenopoulos G. An observational study of sitting out of bed in tracheostomised patients in the intensive care unit. Physiother. 2008;94(4):300-305. [CrossRef]
 
Bourdin G, Barbier J, Burle J-F, et al. The feasibility of early physical activity in intensive care unit patients: a prospective observational one-center study. Respir Care. 2010;55(4):400-407. [PubMed]
 
Nordon-Craft A, Schenkman M, Ridgeway K, Benson A, Moss M. Physical therapy management and patient outcomes following ICU-acquired weakness: a case series. J Neurol Phys Ther. 2011;35(3):133-140. [CrossRef] [PubMed]
 
Norrenberg M, De Backer D, Freidman G, Moraine J-J, Vincent J-L. Cardiovascular response to passive leg movement in critically ill patients. Clin Intensive Care. 1999;10(1):1-6.
 
Chang AT, Boots RJ, Hodges PW, Thomas PJ, Paratz JD. Standing with the assistance of a tilt table improves minute ventilation in chronic critically ill patients. Arch Phys Med Rehabil. 2004;85(12):1972-1976. [CrossRef] [PubMed]
 
Zafiropoulos B, Alison JA, McCarren B. Physiological responses to the early mobilisation of the intubated, ventilated abdominal surgery patient. Aust J Physiother. 2004;50(2):95-100. [PubMed]
 
Skinner EH, Berney S, Warrillow S, Denehy L. Development of a physical function outcome measure (PFIT) and a pilot exercise training protocol for use in intensive care. Crit Care Resusc. 2009;11(2):110-115. [PubMed]
 
Thelandersson A, Cider A, Volkmann R. Cerebrovascular and systemic haemodynamic parameters during passive exercise. Advances in Physiotherapy. 2010;12(1):58-63. [CrossRef]
 
Thelandersson A, Volkmann R, Cider A. Blood flow velocity and vascular resistance during passive leg exercise in the critically ill patient. Clin Physiol Funct Imaging. 2012;32(5):338-342. [CrossRef] [PubMed]
 
Hashim AM, Joseph LH, Embong J, Kasim Z, Mohan V. Tilt table practice improved ventilation in a patient with prolonged artificial ventilation support in intensive care unit. Iran J Med Sci. 2012;37(1):54-57. [PubMed]
 
Cader SA, Vale RG, Castro JC, et al. Inspiratory muscle training improves maximal inspiratory pressure and may assist weaning in older intubated patients: a randomised trial. J Physiother. 2010;56(3):171-177. [CrossRef] [PubMed]
 
Caruso P, Denari SDC, Ruiz SAL, et al. Inspiratory muscle training is ineffective in mechanically ventilated critically ill patients. Clinics (Sao Paulo). 2005;60(6):479-484. [CrossRef] [PubMed]
 
Bissett B, Leditschke IA, Green M. Specific inspiratory muscle training is safe in selected patients who are ventilator-dependent: a case series. Intensive Crit Care Nurs. 2012;28(2):98-104. [CrossRef] [PubMed]
 
Sprague SS, Hopkins PD. Use of inspiratory strength training to wean six patients who were ventilator-dependent. Phys Ther. 2003;83(2):171-181. [PubMed]
 
Bissett B, Leditschke IA. Inspiratory muscle training to enhance weaning from mechanical ventilation. Anaesth Intensive Care. 2007;35(5):776-779. [PubMed]
 
Routsi C, Gerovasili V, Vasileiadis I, et al. Electrical muscle stimulation prevents critical illness polyneuromyopathy: a randomized parallel intervention trial. Crit Care. 2010;14(2):R74. [CrossRef] [PubMed]
 
Gruther W, Kainberger F, Fialka-Moser V, et al. Effects of neuromuscular electrical stimulation on muscle layer thickness of knee extensor muscles in intensive care unit patients: a pilot study. J Rehabil Med. 2010;42(6):593-597. [CrossRef] [PubMed]
 
Poulsen JB, Møller K, Jensen CV, Weisdorf S, Kehlet H, Perner A. Effect of transcutaneous electrical muscle stimulation on muscle volume in patients with septic shock. Crit Care Med. 2011;39(3):456-461. [CrossRef] [PubMed]
 
Zeppos L, Patman S, Berney S, Adsett JA, Bridson JM, Paratz JD. Physiotherapy in intensive care is safe: an observational study. Aust J Physiother. 2007;53(4):279-283. [CrossRef] [PubMed]
 
De Freitas ERFS. Profile and severity of the patients of intensive care units: prospective application of the APACHE II index. Rev Lat Am Enfermagem. 2010;18(3):317-323. [CrossRef] [PubMed]
 
Clavet H, Hébert PC, Fergusson DA, Doucette S, Trudel G. Joint contractures in the intensive care unit: association with resource utilization and ambulatory status at discharge. Disabil Rehabil. 2011;33(2):105-112. [CrossRef] [PubMed]
 
Gosselink R, Bott J, Johnson M, et al. Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on physiotherapy for critically ill patients. Intensive Care Med. 2008;34(7):1188-1199. [CrossRef] [PubMed]
 
Hanekom S, Berney S, Morrow B, et al. The validation of a clinical algorithm for the prevention and management of pulmonary dysfunction in intubated adults—a synthesis of evidence and expert opinion. J Eval Clin Pract. 2011;17(4):801-810. [CrossRef] [PubMed]
 
Hanekom S, Gosselink R, Dean E, et al. The development of a clinical management algorithm for early physical activity and mobilization of critically ill patients: synthesis of evidence and expert opinion and its translation into practice. Clin Rehabil. 2011;25(9):771-787. [CrossRef] [PubMed]
 
Hodgin KE, Nordon-Craft A, McFann KK, Mealer ML, Moss M. Physical therapy utilization in intensive care units: results from a national survey. Crit Care Med. 2009;37(2):561-566. [CrossRef] [PubMed]
 
Stockley RC, Hughes J, Morrison J, Rooney J. An investigation of the use of passive movements in intensive care by UK physiotherapists. Physiotherapy. 2010;96(3):228-233. [CrossRef] [PubMed]
 
Hayes K, Seller D, Webb M, Hodgson CL, Holland AE. Ventilator hyperinflation: a survey of current physiotherapy practice in Australia and New Zealand. New Zealand Journal of Physiotherapy. 2011;39(3):124-130.
 
Jones AY-M. Intensive care physiotherapy–medical staff perceptions. Hong Kong Physiotherapy Journal. 2001;19(1):9-16. [CrossRef]
 
Skinner EH, Berney S, Warrillow S, Denehy L. Rehabilitation and exercise prescription in Australian intensive care units. Physiother. 2008;94(3):220-229. [CrossRef]
 
Norrenberg M, Vincent J-L; European Society of Intensive Care Medicine. A profile of European intensive care unit physiotherapists. Intensive Care Med. 2000;26(7):988-994. [CrossRef] [PubMed]
 
Kumar JA, Maiya AG, Pereira D. Role of physiotherapists in intensive care units of India: a multicenter survey. Indian J Crit Care Med. 2007;11(4):198-203. [CrossRef]
 
Chang AT, Boots R, Hodges PW, Paratz J. Standing with assistance of a tilt table in intensive care: a survey of Australian physiotherapy practice. Aust J Physiother. 2004;50(1):51-54. [PubMed]
 
Chaboyer W, Gass E, Foster M. Patterns of chest physiotherapy in Australian intensive care units. J Crit Care. 2004;19(3):145-151. [CrossRef] [PubMed]
 
Thomas PJ, Paratz JD, Stanton WR, Deans R, Lipman J. Positioning practices for ventilated intensive care patients: current practice, indications and contraindications. Aust Crit Care. 2006;19(4):122-126., 128, 130-132. [CrossRef] [PubMed]
 
Dennis DM, Jacob WJ, Samuel FD. A survey of the use of ventilator hyperinflation in Australian tertiary intensive care units. Crit Care Resusc. 2010;12(4):262-268. [PubMed]
 
Matilainen T, Olseni L. Physiotherapists in general intensive care units in Sweden–professional role, educational preferences and opinion about specialist certification. Nordisk Fysioterapi. 2005;9(2):74-81.
 
Wiles L, Stiller K. Passive limb movements for patients in an intensive care unit: a survey of physiotherapy practice in Australia. J Crit Care. 2010;25(3):501-508. [CrossRef] [PubMed]
 
Stiller K, Wiles L. Patient satisfaction with the physiotherapy service in an intensive care unit. South African Journal of Physiotherapy. 2008;64(1):1-5.
 
Hodgson C, Carroll S, Denehy L. A survey of manual hyperinflation in Australian hospitals. Aust J Physiother. 1999;45(3):185-193. [PubMed]
 
Stiller K. Safety issues that should be considered when mobilizing critically ill patients. Crit Care Clin. 2007;23(1):35-53. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
Physiotherapy in Intensive Care*: Towards an Evidence-Based Practice
Evidence-Based Medicine in the ICU*: Important Advances and Limitations
PubMed Articles
Guidelines
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543