intensive care unit rehabilitation within the united kingdom: review

Physiotherapy September 2003/vol 89/no 9

Professional articles

IntroductionThe Department of Health White PaperComprehensive Critical Care: A review of adultcritical care services (2000) stimulateddebate on outreach services and follow-up clinics. No national guidelines areavailable at present on the developmentand management of these services. Theaim of this study was to establish theextent of current follow-up services in theUnited Kingdom and also to determinethe degree of early rehabilitation availableto patients receiving critical care.

There is well-documented evidence of

the physiological and psychologicalchanges in patients confined to bed incritical care units. Controlled mechanicalventilation requires patients to under-go extended periods of bed rest andimmobility. General muscle atrophy, jointsoreness and loss of proprioception areassociated complications (Haines, 1974;Nava, 1998; Ferrando et al, 1995).

It is now recognised that muscleweakness and atrophy are not simply theresult of prolonged inactivity but ratherthe consequence of myopathic changes.Factors such as malnutrition, sepsis

Intensive Care UnitRehabilitation within theUnited KingdomReview

SummaryBackground and Purpose The survival rate of patients admitted to intensive care is increasing.However, many patients develop symptoms such as generalised muscle weakness and loss of balancefollowing a period of critical illness, and this is no longer thought to be due to bed rest alone.Physiological changes occur as a direct consequence of critical illness and intensive care unit stay.

In recent years a more holistic approach to patient care has evolved, with the development ofrehabilitation programmes. Follow-up clinics provide the opportunity to deliver rehabilitation, from admission to intensive care through to discharge home and beyond. These developments are reflected in the continually evolving role of physiotherapists in intensive care.

This study explores the current service provision of rehabilitation within intensive care unitsthroughout the United Kingdom. It reveals the outcome measures currently in use, and looks atphysiotherapists’ experience and perception of follow-up services for intensive care patients.

Methods A questionnaire survey was carried out involving senior I physiotherapists working onintensive care units in 36 teaching/large district general hospitals throughout the United Kingdom. It comprised 13 questions that collected both qualitative and quantitative data.

Results Only 38% of staff questioned work full time in intensive care; however 100% of staff offerrehabilitation in some form; 97% offer passive movements and 100% offer musculoskeletal assessmentand an exercise regime. Only 21% of physiotherapists use recognised outcome measures. 93% feelthere is a role for physiotherapists in an intensive care unit follow-up service. 86% have experienced or foresee difficulties in running such a service, identifying the main difficulty as staff shortages.

Conclusions Rehabilitation programmes are in evidence in intensive care units throughout the United Kingdom. However there are few standardised outcome measures suited to this group ofpatients, and they should be developed for use in intensive care units to facilitate evaluation. More research into the effects of rehabilitation on this particular diverse patient group is needed.Physiotherapists need to be involved in the setting up and delivery of follow-up services.

Key WordsRehabilitation, intensive care,outcome measures, follow-upclinics.

by Maria Lewis

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Lewis, M (2003).‘Intensive care unitrehabilitation withinthe United Kingdom:Review’, Physiotherapy,89, 9, 531-538.


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and pharmacological agents may allcontribute to the myopathic disturbances(Bruton et al, 2002).

Critical care is one of the most stress-ful environments that patients canexperience. Admission to hospital canupset their psychological well-being asthey often take on the ‘dependent role’(MacKellaig, 1987). This can be acc-entuated in intensive care units by theirinability to communicate, which mayresult in feelings of despair, fear,frustration and anger (Riggio et al, 1982).These can develop into abnormal psych-ological disturbances, visual hallucina-tions, gross disorientation and paranoia(Fisher and Moxham, 1984), accompan-ied by feelings of anxiety, restlessness,apathy, and inability to concentrate. The occurrence of these symptoms isrecognised as ‘intensive care syndrome’(Benzer et al, 1983; Fisher and Moxham,1984; MacKellaig, 1987; McKegney, 1966).

With continuing advances in intensivecare medicine, increasing numbers ofpatients survive their stay in intensive careunits (King and Crowe, 1998).

Patients who survive are more likely tohave a poorer Health Related Quality ofLife (HRQL) score than the generalpopulation (Chaboyer and Elliot, 2000).There is also a higher incidence ofpsychological morbidity, particularlyintensive care unit-related post-traumaticstress disorder and depression (Friedmanet al, 1992; Perrins et al, 1998). Patientsalso report problems with general weak-ness and poor balance control associatedwith fear of falling after discharge home(Jones and Griffiths, 2000).

Regular physical activity enhances thefunctional capacity of many organs of the human body (Ferrando et al, 1995).Rehabilitation of these patients has beenshown to help facilitate weaning frommechanical ventilation and dramaticallyimproves exercise tolerance, thus con-tributing to an earlier discharge fromintensive care (Nava, 1998; King andCrowe, 1998).

This highlights the importance of early rehabilitation, allowing patients toachieve their best possible functionalability before discharge.

Norrenberg and Vincent (2000) set out to develop a profile of Europeanphysiotherapists working in intensive careunits. They sent postal questionnaires to460 intensive care units in 17 western

European countries, and asked physio-therapists about their position, role,education and the involvement of theprofession in patient care. The responserate of 22% was very low. Their method ofrecruiting physiotherapists, throughsenior intensive care unit physiciansrather than addressing physiotherapistsdirectly, may have contributed to the lowresponse rate.

Only seven of the 17 countries had ahigh enough response rate to be includedin the data analysis. These response rates varied from 29/60 questionnairesreturned by units in the United Kingdom,to 4/22 questionnaires returned bySweden. The results from the sevencountries included showed that 75% ofintensive care units had at least onephysiotherapist working exclusively in theunit. Of the respondents, 33% reportedavailability of an overnight physiotherapyservice, with 83% reporting availability ofa physiotherapist at the weekend.

The active professional role of phys-iotherapists varied from country tocountry and included mobilisation,respiratory therapy, positioning, airwaysuction, implementation and supervisionof non-invasive ventilation, extubation,supervision of weaning from mechanicalventilation, adjustment of mechanicalventilation and intubation. The authorsconcluded that the involvement of phys-iotherapists in specialised techniques was directly related to the number ofphysiotherapists working in an intensivecare unit.

With such a poor response rate thatstudy cannot provide a true profile ofEuropean intensive care physiotherapists.The report states that the majority ofphysiotherapists perform both respiratoryrelated techniques and mobilisation(physical) physiotherapy but does notelaborate further on what this involves.

There is some evidence to show theeffectiveness of physiotherapy techniquessuch as positioning, manual hyper-inflation, suction, use of non-invasiveventilation and intermittent positivepressure breathing on critically ill patients(Brookes et al, 2001; Deokule, 1998; Kingand Morrell, 1992; Denehy and Berney,2001; Kramer et al, 1995). A number ofstudies also show the benefits of laterehabilitation programmes such aspulmonary and cardiac rehabilitation(Griffiths et al, 2001; Williams, 2001).


533Research report

However, very few studies have lookedspecifically at the benefits of earlyrehabilitation for critically ill patients.

Nava (1988) examined the effect ofpulmonary rehabilitation on physiolo-gical variables in chronic obstructivepulmonary disease patients who had beenadmitted to a respiratory intensive careunit. Eighty patients were recovering froman episode of acute respiratory failure.Those conforming to the inclusioncriteria were randomised into two groupsusing a 3:1 ratio. Group A received acomprehensive rehabilitation programmeand group B received standard medicaltherapy and progressive ambulationalone. Patients enrolled in group Abenefited more than those in group BThe main limitation of this study was thatdue to ethical constraints, which specifiedthat only 1 in 4 patients were allocated togroup B, and meant that the groups werenot equal and the size of group limitedthe analysis and conclusions.

There have also been a number ofstudies that look at the physiologicaleffects of positioning, exercise andstretching in patients with neurologicalconditions such as head injury and spinalcord injury, demonstrating some phys-iological benefits of early, regularintervention (Brimioulle et al, 1997;Harvey et al, 2000).

In intensive care, patients often havemultiple pathology and rehabilitation has to be tailored to their individualneeds and capabilities. This may involvemusculoskeletal assessment and devel-opment of specific exercise regimes. Itmay also involve the use of tilt tables andstanding frames or hoists to sit patientsout in chairs. The need to make rehab-ilitation patient-specific adds to thedifficulty of researching its benefits.

It is widely acknowledged that the mainaims of rehabilitation are to:

■ Increase functional independence.

■ Minimise adverse effects associatedwith bed rest, such as muscle atrophyand joint stiffness.

■ Improve psychological well-being.

■ Aid with weaning from mechanicalventilation.

■ Decrease the length of stay onintensive care units (Nava, 1998; King and Crowe, 1998).

Standardised outcome measures areessential to allow therapists to documentthe clinical effect of treatment and facil-itate audit and research (Mayo, 1994).

The Department of Health aims tostandardise the level of care available to patients on intensive care unitsthroughout the United Kingdom. Itadvocates a move towards patient-centredholistic care, addressing patients’ needsfrom their admission to discharge fromhospital (DoH, 2000). The developmentof outreach teams and follow-up clinics isexpected to facilitate this approach.

AimsThree aims were identified for the studyreported here: ■ To explore current provision of

rehabilitation within intensive careunits throughout the United Kingdom.

■ To document the outcome measurescurrently in use.

■ To look at the physiotherapists’experiences and perception of follow-up services for intensive care unitpatients.

MethodStudy DesignA questionnaire was developed whichcomprised 13 questions that collectedboth qualitative and quantitative data. Amixture of both open-ended and closedquestions allowed standardised responsesbut provided space for therapists toelaborate on their answers if necessary.The questionnaire was accompanied by acovering letter detailing the aims of thestudy, and a stamped addressed envelopeto encourage a high response rate.

SubjectsThe Directory of Surgery was used to obtainthe addresses of 36 teaching hospitals and large district general hospitals thatwere listed within the United Kingdomwhich had either a number of specialistintensive care units, or large generalintensive care units.

In view of the poor response rateachieved by Norrenberg and Vincent(2000) it was decided that the quest-ionnaires should be addressed to senior Iphysiotherapists, rather than to intensivecare unit physicians, with the hope thatthis would improve response rates. Datawere analysed using descriptive statistics.

Author and Addressfor Correspondence

Maria Lewis BScMCSP is a seniorphysiotherapist incritical care at theUniversity Hospital ofWales, Heath Park,Cardiff, South WalesCF4 4XY.

Acknowledgements

Grateful thanks areextended to Carole Jones andMary Ann Broad,PhysiotherapyDepartment,University Hospital ofWales, Cardiff and toUna Jones, School ofPhysiotherapy,Cardiff, forconstructive adviceand support.


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ResultsResponse RateOf the 36 questionnaires sent, 29 werereturned, giving a response rate of 80.5%.Of the 29 returned questionnaires, allhospitals had intensive care units. Thenumber within each hospital is shown intable 1.

Therapists were asked to indicate whichregional specialties were representedwithin these units. The results are illust-rated in the figure below.

The average number of intensive careunit beds on each unit was 10 (range 4 to 30).

Although only 11 respondents (38%)indicated that the staff worked full time inintensive care, 29 (100%) reported thatthey offered some form of rehabilitationfor intensive care patients. Table 2 showsthe components of the rehabilitationprogramme offered.

Therapists were asked whether theyused any form of standardised outcomemeasure for rehabilitation in intensive

care. Only 6 (21%) reported that theydid. The following outcome measureswere used:

■ Borg scale of breathlessness.■ Oxford muscle grading.■ 10-metre walk test.■ Hand function/grip strength.■ Sit to stand (minimum height

achieved).■ 180˚ turn (number of steps taken).■ Pulmonary function tests.■ Estimates of oxygen uptake during

exercise using heart rate and ratepressure product calculated as theproduct of systolic blood pressure and heart rate.

■ Shuttle walk tests.

Twenty-seven therapists (93%) felt thatphysiotherapy had a role to play inintensive care follow-up after dischargefrom hospital, yet only 14 hospitals (48%)were reported to offer any form of follow-up outpatient service from a member of

Table 1: Number of intensive care units per hospital

Number of Number (%) of hospitalsintensive care units

1 11 (38)

2 13 (45)

3 3 (10)

4 1 (3)

5 0

6 1 (3)

Table 2: Different forms of rehabilitation in anintensive care unit

Rehabilitation Number (%) of intensive care units

Passive movements 28 ( 97)

Tilt table 25 (86)

Hoisting into chair 26 (90)

Standing frame 17 (59)

Musculoskeletal assessment and exercise regime 29 (100)

Others 20 (69)

Distribution of regional specialties in intensive care units

Number of intensive care units

Cardiothoracics

Burns/Plastics

Trauma

Neurosurgery/Neurosciences

Liver/Renal

Upper gastro-intestinal/Pancreatitis

Others

None

Regional Specialties

2 4 6 8 10 12 140


535Research report

the intensive care team. Where some formof outpatient follow-up service was inplace, information was sought on the typeof service available (table 3).

Respondents were asked whether theyfelt the follow-up service offered waseffective. Seven respondents (50%) feltthat it was, five (36%) did not and two(14%) made no comment.

Similarly, 26 (86%) had experienced orfelt that there would be difficulties inrunning an intensive care follow-upservice. Two (7%) saw no difficulty and 2 (7%) declined to comment. A furtherquestion elicited information on wherephysiotherapists had experienced orpredicted difficulties (table 4).

Discussion The study response rate of 80.5% wassignificantly higher than that reported by Norrenberg and Vincent (2000). How-ever those authors were questioningphysiotherapists from all over Europe,whereas this study only involved phys-iotherapists in the United Kingdom.

The results of the study show that

rehabilitation is offered in the majority ofintensive care units in the UnitedKingdom. Follow-up clinics are also beingestablished.

The data show that most hospitals haveat least two intensive care units, with anaverage of ten beds per unit. There weremany different specialty intensive careunits listed throughout the UnitedKingdom, the most common reported ascardiothoracic surgery. Five intensive careunits were general, with no regionalspecialty.

This section also aimed to compare theratio of staff to beds across the UnitedKingdom, but because of ambiguities inthe question the data could not be inter-preted with certainty. This is recognised as a limitation.

The adverse physical and psychologicaleffects of a long stay in intensive care are well documented. Long-term bed restcan lead to generalised weakness, jointsoreness and loss of proprioception(Haines, 1974; Nava, 1998; Ferrando et al,1995). Factors such as malnourishment,use of steroids and development of sepsis are now also recognised to triggermyopathic changes in these patients(Bruton et al, 2002). Psychologicaldisturbances such as ‘intensive caresyndrome’ can manifest as a result of aprolonged stay and patients can sufferfrom post traumatic stress disorder after discharge. Rehabilitation aims tominimise these changes. This study hasshown that many units offer rehabilitationbut that this can take many forms.

Studies that have been carried out onspecific groups of patients show thebenefits of early rehabilitation (Nava,1998; King and Crowe, 1998; Brimioulle etal, 1997).

TechniquesOne question referred to the types ofrehabilitation provided. Apart from theexamples listed in the question otherforms of rehabilitation were reportedincluding ambulatory ventilation, ass-essment of joint movement, casting andsplinting. The most common ‘other’forms of rehabilitation were sitting thepatient over the edge of the bed, andspeaking valve techniques.

Very few therapists reported usingoutcome measures to evaluate the effectsof intervention. A small minority ofphysiotherapists (21%) stated that they

Table 3: Types of follow-up service available

Follow-up service Number (%) of hospitals offering service

Intensive care unit consultant 11 (38)

Specialist nurse 10 (35)

Multidisciplinary intensive care team 5 (17)

Pain management clinics 0

Tracheostomy clinics 2 (7)

Other 2 (7)

None 12 (41)

Table 4: Difficulties experienced or foreseen in intensive care unit follow-up

Difficulties Number (%) of therapists experiencing or predicting

difficulties

Staff shortages 14 (48)

Time restraints 5 (17)

Tertiary referral centre 4 (14)

Funding 7 (24)

Resources 3 (10)

Blurring of professional boundaries 2 (7)

Space 2 (7)

Source of referrals 1 (3)


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did use outcome measures, assessingeither patients’ respiratory system orfunction. None of the outcome measuresstated were specifically validated forintensive care unit use. Some of theoutcome measures were written in theirabbreviated form with no explanation,therefore their appropriateness could notbe evaluated. The lack of a validatedintensive care unit specific outcomemeasure became apparent.

Standardised outcome measures neednot be complex, and it is imperative thatthey are used both for research andclinical purposes. Nava and Ambrosino(2000) emphasise the importance ofsimple outcome measures such as severityof dyspnoea, pulmonary function tests,and physical limitations (eg using theactivity of daily living scale) to show thevalue of a given intervention.

Follow-upThe last part of the questionnaireaddressed the use and extent of follow-up.The document Comprehensive Critical Care(DoH, 2000) emphasises the importanceof long-term support and follow-up ofcritically ill patients after discharge fromhospital. It suggests the implementationof follow-up clinics to provide thenecessary psychological and physiologicalsupport.

Only 14 hospitals (48%) were reportedto offer some form of follow-up outpatientservice from a member of the intensivecare unit team.

The study shows that the majority ofthese follow-up clinics are either nurse orconsultant led – 10 (33%) and 11 (38%)respectively – and only 5 (17%) of follow-up clinics are multi-disciplinary.

A number of other forms of follow-upwere reported. One hospital had a criticalcare outreach team that was nurse led,with consultant support. Another hospitaloffered follow-up if requested by anoutreach team, but the type of service wasnot defined. Also reported was a nurse ledoutreach service, where physiotherapistscould refer to musculoskeletal outpatientclinics if necessary. The benefits ofreferring intensive care patients to amusculoskeletal outpatient setting havenot been explored, but may have somelimitations. One of the hospitals surveyedoffered a follow-up with a respiratoryconsultant.

Our study found that 93% of physio-

therapists felt there was a role for physio-therapy in an intensive care follow-upservice. They felt it was essential in orderto assess whether patients had achievedtheir full functional potential followingdischarge, to ensure that any musculo-skeletal problems were identified,pulmonary rehabilitation facilitated ifappropriate, and psychological supportgiven.

It was emphasised that follow-up neededa global multi-disciplinary approach,working closely with colleagues within thecommunity setting.

Jones and Griffiths (2000) set out toidentify mobility problems in intensivecare unit patients following hospitaldischarge, and the factors that bestpredict a need for physical rehabilitation.They invited patients who had spentlonger than five days in intensive care to afollow-up clinic eight weeks afterdischarge from the unit. A total of 160patients were seen in the outpatientclinic. Time and resource limitations wereidentified within both the acute andcommunity settings.

The report suggested that while therewas a body of literature describingpsychological problems followingdischarge from intensive care, there waslittle to describe physical problems.

One physiotherapist stated that therewas a poor attendance rate at follow-upclinic. This may be a problem if thefollow-up clinic is within a tertiary referralhospital that has a large geographicalpopulation. A number of physiotherapistshad only recently introduced the service,so evaluation audits were not yet com-plete.

Difficulties in running an intensive care unit follow-up service had beenexperienced or foreseen by 86% of resp-ondents. The most common prob-lems identified were staff shortages, timerestraints, and limited resources. Anumber of hospitals had started serviceswithout proper funding or staff allocation.It is likely that this has put pressure onexisting services which may already havebeen under-staffed and under-resourced.

LimitationsIt was not possible to compare thenumber of physiotherapy staff working oneach unit because some answers weregiven in whole-time equivalents, somewere given in grades, and some were


537Research report

given as a number. The question neededto be more specific, so that the ratio ofwhole-time equivalent staff to bednumbers could have been calculated foreach unit. A separate question should alsohave been added to determine the grademix across each intensive care unit.

Some of the outcome measures thatwere listed were given only in anabbreviated form with no explanation ofwhat they were. Their validity, reliabilityand appropriateness could not beassessed.

The term ‘follow-up’ was not clearlydefined within the questionnaire and thisled to some misunderstanding. Thereseemed to be some confusion betweenthe terms ‘outreach’ and ‘follow-up’.

A number of responses corresponded toward-based physiotherapy on dischargefrom the intensive care unit. This is notthe form of follow-up on which thequestionnaire sought information.

ConclusionIt is evident that intensive care unitsthroughout the United Kingdom haverehabilitation programmes. Various typesare offered; 97% of physiotherapists carryout passive movements and 100% carryout a musculoskeletal assessment andexercise regime. Only 21% of respond-ents use any form of standardisedoutcome measure.

There is a dearth of literature on thebenefits of early rehabilitation and on thespecific form that should be used for thispatient group. Further research into thisarea is needed. The first step must be toidentify any common physiologicalproblems that result from an intensivecare unit admission. It is important toestablish whether given patients are moresusceptible to problems than others, forexample, patients with sepsis.

Once problems have been identified,appropriate positioning and rehabilit-ation programmes can be implemented.

Validated outcome measures are neededto evaluate the effects of rehabilitation.The use of a comprehensive rehabilitationprogramme aimed at improving functionand quality of life may shorten hospitalstay and prevent readmission. Yet nopublished research looks at the benefits ofearly rehabilitation in a general intensivecare unit.

Follow-up is now being implementedthroughout the United Kingdom invarious forms. The consensus is that it needs to have a multi-disciplinaryapproach, with physiotherapy having a very definite role to play in thecontinuing rehabilitation and reinteg-ration of critical care patients back into anormal lifestyle.

There are indications of problems instaffing and resourcing existing services,without further expansion. Althoughthere is some evidence to justify provisionof a follow-up service, apprehension wasexpressed about the ability to secureadequate resources to provide the service.

The role of physiotherapists withinfollow-up services needs further invest-igation, particularly in the balancebetween providing rehabilitation andacting as a link between acute andcommunity services. A large number ofintensive care units are within tertiaryreferral centres. Geographically it may notbe appropriate for all patients to attendfollow-up at these centres. Satellite clinicsmay be an option, but close links need tobe established between intensive care unitphysiotherapists and community teams.Are the community services available thatthis patient group requires?

These patients may not have specificjoint pathology, but instead present withvarying degrees of generalised muscleatrophy and balance disturbance, whichmay be best treated by individualisedrehabilitation programmes. However, theoptimum management of these patients is still uncertain.

References

Benzer, H, Mutz, N and Pauser, G (1983).‘Perceived noise in surgical wards andintensive care areas: An objective analysis’,International Anaesthesiology Clinics, 22, 169-180.

Brimioulle, S, Moraine, J J, Norrenberg, D and Kahn, R J (1997). ‘Effects of positioningand exercise on intracranial pressure in a neurosurgical intensive care unit’, Physical Therapy, 12, 1682-89.

Brooks, D, Anderson, C M, Carter, M A et al(2001). ‘Clinical practice guidelines forsuctioning the airway of the intubated andnon-intubated patient’, Canadian RespiratoryJournal, 3, 163-181.

Bruton, A, Conway, J H and Holgate, S T(2002). ‘Inspiratory muscle dysfunction afterprolonged periods of mechanical ventilation’,Physiotherapy, 88, 131-137.


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Chaboyer, W and Elliot, D (2000). ‘Health-related quality of life of intensive care unitsurvivors: Review of the literature’, Intensiveand Critical Care Nursing, 16, 2, 88-97.

Department of Health (2000). ComprehensiveCritical Care: A review of adult critical care services,HMSO.

Denehy, L (1999). ‘The use of manualhyperinflation in airway clearance’, EuropeanRespiratory Journal, 14, 958-965.

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Deokule, K (1998). ‘Effects of body position on gas exchange with relation to mechanicalventilation and ventilation/perfusion’, Journal of the Association of CharteredPhysiotherapists in Respiratory Care, 3, 24-28.

Ferrando, A A, Lane, H W, Stuart, C A, Davis-Street, J and Wolfe, R R (1995).‘Prolonged bed rest decreases skeletal muscle and whole body protein synthesis’,American Journal of Physiology, 270, E627-E633.

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Key Messages

■ Critical illnesscausesphysiologicalchanges to nerveand muscle thatare no longerthought to be dueto bed rest alone.

■ Patientsdischarged fromintensive care unitshave poorer HealthRelated Quality ofLife scores thanthe generalpopulation.

■ Diverserehabilitationmodalities are usedin intensive careunits, but use ofoutcome measuresto evaluate practiceis limited.

■ Standardisedoutcome measuresneed to bedeveloped for usein intensive care,and furtherresearch isrequired on theeffects of earlyrehabilitation onthe functionalabilities of thisdiverse patientgroup.

■ Physiotherapistsshould be involvedin the setting upand delivery offollow-up services.

intensive care unit rehabilitation within the united kingdom: review

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