Critical Illness

Special Series

Physical Therapy on the Wards After

Early Physical Activity and Mobility in
the Intensive Care Unit
R.O. Hopkins, PhD, Department of
Medicine, Pulmonary and Critical
Care, Intermountain Medical Center, 5121 S Cottonwood St, Murray,
UT 84107 (USA), and Psychology
Department and Neuroscience
Center, Brigham Young University, Provo, Utah. Address all correspondence to Dr Hopkins at:
mona.hopkins@imail.org.
R.R. Miller III, MD, MPH, Department of Medicine, Pulmonary and
Critical Care, Intermountain Medical Center, and Department of
Medicine, Pulmonary and Critical
Care, University of Utah School of
Medicine, Salt Lake City, Utah.
L. Rodriguez, AS, Department of
Medicine, Pulmonary and Critical
Care, Intermountain Medical
Center.
V. Spuhler, RN, MSN, Department
of Medicine, Pulmonary and Critical Care, Intermountain Medical
Center.
G.E. Thomsen, MD, Department
of Medicine, Pulmonary and Critical Care and Cardiovascular
Department, Intermountain Medical Center.
[Hopkins RO, Miller RR III, Rodriguez L, et al. Physical therapy on
the wards after early physical
activity and mobility in the intensive care unit. Phys Ther.
2012;92:1518 1523.]
2012 American Physical Therapy
Association
Published Ahead of Print:
April 5, 2012
Accepted: March 26, 2012
Submitted: December 2, 2011

Ramona O. Hopkins, Russell R. Miller III, Larissa Rodriguez, Vicki Spuhler,

George E. Thomsen

Background. Weakness and debilitation are common following critical illness.

Studies that assess whether early physical activity initiated in the intensive care unit
(ICU) continues after a patient is transferred to a ward are lacking.
Objective. The purpose of this study was to assess whether physical activity and
mobility initiated during ICU treatment were maintained after patients were discharged from a single ICU to a ward.

Design. This was a cohort study.

Methods. Consecutive patients who were diagnosed with respiratory failure and
admitted to the respiratory ICU (RICU) at LDS Hospital underwent early physical
activity and mobility as part of usual care. Medical data, the number of requests for
a physical therapy consultation or nursing assistance with ambulation at ICU discharge, and mobility data were collected during the first 2 full days on the ward.

Results. Of the 72 patients who participated in the study, 65 had either a physical
therapy consultation or a request for nursing assistance with ambulation at ward
transfer. Activity level decreased in 40 participants (55%) on the first full ward day.
Of the 61 participants who ambulated 100 ft (30.48 m) or more on the last full RICU
day, 14 did not ambulate, 22 ambulated less than 100 ft, and 25 ambulated 100 ft or
more on the first ward day.

Limitations. Limitations include lack of data regarding why activity was not
performed on the ward, lack of longitudinal follow-up to assess effects of activity, and
lack of generalizability to patients not transferred to a ward or not treated in an ICU
with an early mobility program.
Conclusions. Despite the majority of participants having a physical therapy
consultation or a request for nursing assistance with ambulation at the time of transfer
to the medical ward, physical activity levels decreased in over half of participants on
the first full ward day. The data suggest a need for education of ward staff regarding
ICU debilitation, enhanced communication among care providers, and focus on the
importance of patient-centered outcomes during and following ICU treatment.

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Activity on the Ward After ICU

ecreased mortality associated

with progress in critical care
results in increasing numbers
of survivors of an intensive care unit
(ICU) admission.1 For many ICU survivors, critical illness and its treatment result in significant long-term
morbidities.2 4 Survivors of critical
illness have neuromuscular morbidities that persist years after ICU discharge and restrict mobility, recreational pursuits, and autonomy and
subsequently decrease quality of
life.5 Patients who are critically ill
have debilitating limitations in physical function at ICU discharge that
persist months to years after ICU discharge.4 The rate of recovery and
return to pre-illness function following critical illness may be slowed by
immobilization.6,7

In a study by Thomsen et al,12

patients who were critically ill and
diagnosed with respiratory failure
increased ambulation after transfer
from another ICU to the respiratory
intensive care unit (RICU), where
early activity was a priority, suggesting that the usual ICU environment
may result in unnecessary immobilization. However, no studies have
evaluated whether early physical
activity and mobility initiated in the
ICU environment continue after a
patient is transferred from the ICU to
a ward. The purpose of this study
was to determine whether physical
activity and mobility initiated during
ICU treatment were maintained after
patients were transferred from the
ICU to a ward.

Method
Early physical activity in the ICU
aims to ameliorate post-ICU physical
morbidity. Early physical activity in
the ICU is safe and feasible in
patients who are critically ill.8,9 In a
study by Morris et al,10 patients who
were critically ill and diagnosed with
respiratory failure and who received
protocolized mobility were out of
bed sooner, had physical therapy
sooner in the ICU, had more physical
therapy intervention sessions, and
had shorter ICU and hospital length
of stays compared with patients who
received usual care.10 A follow-up
study of ICU readmission in patients
who underwent protocolized mobility compared with usual care
showed that lack of early ICU mobility, tracheostomy, female sex, and
higher Charlson Comorbidity Index
scores were associated with hospital
readmission or death 1 year after ICU
discharge.11 Early ICU activity and
mobility resulted in shorter duration
of delirium, shorter duration of
mechanical ventilation, shorter ICU
length of stay, and improved functional outcomes (eg, higher Barthel
Index scores, increased distance
ambulated, larger number of unassisted activities of daily living).9
December 2012

This cohort study assessed 300 consecutive mechanically ventilated

patients who were critically ill and
diagnosed with respiratory failure
and who were admitted to the 8-bed
RICU at LDS Hospital from January 1
to December 31, 2006. Many
patients admitted to the RICU were
admitted from another medical or
surgical ICU at LDS Hospital. All
patients underwent early physical
activity and mobility as part of usual
care in the RICU. Study inclusion criteria were respiratory failure, RICU
stay longer than 2 days, transfer to a
ward, and ward stay longer than 2
days. The duration of stay criteria
were applied to ensure adequate
exposure to each environment to
evaluate activity. Respiratory failure
was defined as requiring more than
4 days of mechanical ventilation
because these patients are theoretically at greater risk for developing
physical debilitation. Exclusion criteria were open abdomen, neurologic
disease (stroke or paralysis) that precluded activity, and terminal illness.
The LDS Hospital Institutional
Review Board approved the study
and waived the requirement for
informed consent.

Participants diagnosed with respiratory failure underwent early activity

and mobility using a previously published early activity protocol while in
the RICU.8,12 The goal of the activity
protocol was to ambulate farther
than 100 ft (1 ft0.3048 m). Walking
was determined by the staff as an
important patient-centered functional
outcome. Activity events included
passive and active range of motion,
sitting on the edge of the bed without back support, transferring from
bed to a chair, and ambulating. Activity level progressively increased
from lower to higher (eg, from sitting in a chair to ambulating) in
twice-daily
physical
therapy
sessions.8,12
We collected demographic and clinical data, including duration of
mechanical ventilation, length of
stay, Acute Physiology and Chronic
Health Evaluation II (APACHE II)
scores,13 and Charlson Comorbidity
Index, a weighted score that takes
into account the number of comorbid diseases and their seriousness.14
We also recorded participants
requests for physical therapy on the
ward. A priori we included activity
requests for either a physical therapy
consultation or nursing assistance
with ambulation. Reasons for a physical therapy consultation or a request
for nursing assistance with ambulation were not recorded. We also collected mobility data for the last 2 full
days in the RICU and the first 2 full
days on the ward. We recorded
whether a participant walked and,
if so, whether he or she was able to
walk farther than 100 ft. Physical
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Activity on the Ward After ICU

Figure 1.
Study flow diagram. RICUrespiratory intensive care unit, ICUintensive care unit.

therapists recorded the distance

walked during ward treatment, and
nurses recorded only whether an
individual walked.

Role of the Funding Source

There was no outside financial support for this study.

Results
Each participant served as his or her
own control, allowing comparison
of activity during RICU treatment
with activity on the ward on a
patient-by-patient basis. Changes in
activity were assessed across RICU
transfer to the ward. Descriptive statistics were reported for demographic, medical, and activity data.
Continuous data are presented as
meansstandard deviations, medians, and ranges. Categorical data are
presented as number and percentage.

Of the 300 patients screened, 228

were excluded from the study and
72 formed the study cohort. Figure 1
shows the study flow diagram. The
mean age of the participants was
61 years. Fifty percent of the participants were female. Participant
demographic and medical data are
summarized in the Table. On the last
full RICU day, the mean distance
ambulated was 182 ft (SD130,
median150, range0 500).

Table.
Demographic and Medical Data of Study Cohort (n72)a
Demographic and Medical Variables

XSD

Range

Median

60.914.2

3389

61.0

APACHE II score

21.85.7

1244

21.0

Duration of mechanical ventilation (d)

12.05.7

444

9.4

Total ICU length of stay (d)

19.410.8

650

16.9

Total RICU length of stay (d)

11.17.2

232

9.1

Age (y)

Ward length of stay (d)

Hospital length of stay (d)
Charlson Comorbidity Index score
a

6.56.2

249

4.9

29.320.8

8131

22.6

4.12.9

011

4.0

APACHE IIAcute Physiology and Chronic Health Evaluation II, ICUintensive care unit,
RICUrespiratory intensive care unit.

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Sixty-five participants (90%) had an

activity plan of either a physical therapy consultation or mobility orders
written for nurses. A physical therapy consultation was requested for
49 participants (68%) at RICU transfer. An additional 16 participants had
mobility orders written for nursing
assistance with ambulation in the
hallway.
Activity levels decreased in 40 participants (55%) on the first full day
on the ward compared with their
activity levels on the last full RICU
day (Fig. 2). Figure 3 shows ambulation by type of activity consultation
requested on the first full ward day.
Regardless of type of consultation
(no consultation requested, a request
for nursing assistance with ambulation, or a physical therapy consultation), 52 participants ambulated.
Twenty-seven participants ambulated
100 ft, and 26 participants ambulated 100 ft. Twenty of the 65 participants who had a request for nursing assistance with ambulation or a
physical therapy consultation did
not ambulate on the first full day on
the ward.
We also compared ambulation on
the last RICU day and on the first full

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Activity on the Ward After ICU

Figure 2.
Change in activity level comparing patients activity level on the last full respiratory intensive care unit (RICU) day with activity on
the first full ward day. The light blue bar shows the number of patients whose activity level decreased. The dark blue bar shows the
number of patients who had no change in activity level. The black bar shows the number of patients whose activity level increased.

Figure 3.
Number of patients who ambulated and type of ambulation on the first full day on the ward by type of physical therapy consultation:
no consultation, nursing assistance with ambulation, or physical therapy consultation. The dark blue bars show the number of
patients who had a consultation for a physical therapist to ambulate by distance ambulated. The light blue bars show the number
of patients who had a request for nursing assistance with ambulation by distance ambulated. The black bars show the number of
patients who had no physical therapy consultation at intensive care unit transfer by distance ambulated.

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ward day categorically: no ambulation, ambulation 100 ft, and ambulation 100 ft. Of the 61 participants
who ambulated 100 ft on the last
full RICU day, 14 did not ambulate,
22 ambulated 100 ft, and 25 ambulated 100 ft on the first ward day.
Of the 8 participants who ambulated
100 ft on the last RICU day, 3 did
not ambulate, 4 had no change
(ambulated 100 ft), and 1 increased
the distance ambulated (100 ft) on
the first ward day. Three participants
did not ambulate on the last full
RICU day or on the first day on the
ward.

Discussion
Most participants (90%) had a
request for consultation for physical
activity on the ward after RICU transfer. However, 55% of the participants had a decrease in activity from
the last full day in the ICU to the
first full day on the ward. The RICU
focus on patient-centered outcomes
such as functional independence is
reflected by the high rate of ambulation and by the number of participants who had requests for consultations for physical therapy upon
transfer. Previous work has supported the association between culture and practice of early physical
therapy and mobility in the ICU.12
However, in the present study, the
culture of early mobility did not
appear to carry over to the ward.
As noted above, more than half of
the participants had a decrease in
activity from the last full day in the
ICU to the first full day on the ward.
In 19% of the participants who
ambulated 100 ft in the ICU, the
decrease in activity level was marked
(ie, no documented mobility on
the ward). This finding is especially
surprising given that it is arguably
easier to mobilize patients who
have been extubated and who are
less critically ill. More specifically,
when a patients medical condition
improves enough to justify ICU dis1522

charge, it might be expected that

activity would remain stable or
improve. Regardless, the decrease in
activity on the ward was not due to
lack of a request for consultation
for physical therapy or for nursing
staff to mobilize the patients. Unfortunately, the reasons for a change
in activity level from the ICU to
the ward were not recorded
prospectively.
Possible reasons for the change in
activity include patient fatigue,
patient refusal, increase in the
patient-to-staff ratio on the ward, and
inefficient communication about the
patients physical function from the
ICU to ward personnel during transfer. Patients experience significant
fatigue in the ICU, so fatigue alone
cannot account for the decrease in
activity. Insufficient communication
or information gaps during medical
transfer are reported in a number of
medical settings, including transfer
of patients with trauma from emergency medical services to in-hospital
personal15 and transfer of elderly
patients from a nursing home to the
emergency department.16 Carter and
colleagues15 found only 73% of key
prehospital data were reported to
in-hospital personnel; data such as
hypotension, other vital signs, and
Glasgow Coma Scale scores often
were not recorded. In a study of
patients with trauma, approximately
25% of relevant information was not
recorded or reported by prehospital
personnel to the in-hospital team.17
The authors concluded that documentation of important clinical data
during handover and standardization of information at patient transfer
(eg, development of a standard transfer sheet) are needed to improve
information transmission during critical transfers.17 We do not know
whether loss of information during
patient transfer or handoff contributed to the decrease in activity level
in our patients.

Another
possible
reason
for
decreased activity may be cultural.
That is, the importance of activity
may be different between ICU staff
and ward staff, even though functional independence is critical on the
ward. Thomsen et al12 found that
transfer to an ICU where activity was
a key component of patient care
resulted in a significant increase in
ambulation independent of patients
pathophysiology. Encouraging a culture change on the ward may be useful. However, such culture change
may vary from ward to ward, with
each ward having a unique culture
and environment. For instance,
transfer to an orthopedic ward might
result in more aggressive physical
therapy intervention than transfer
to an oncology ward. Regardless of
ward culture, the patients needs are
what should drive care, not their
location. A first step in culture
change on the ward may be education of staff regarding the physical
debilitation that occurs in the ICU
and the importance of physical therapy intervention and mobility in ICU
survivors. Encouraging wards to
embrace similar patient-centered
outcomes as the ICU might also help.
Alternatively, cultural differences
may reflect differences in patient-tostaff ratios on the ward, with ward
staff having larger patient loads.
Larger patient load might make coordination of activity and mobility
more difficult or more susceptible to
time constraints of patient treatments, fatigue, or medical or radiological procedures. For instance,
heavy work load may not allow staff
to come back at a later time to complete an activity that was deferred
due to a competing diagnostic procedure. One solution might be to
have activity become a planned care
process, much like obtaining blood
glucose serially in patients with diabetes on the ward.
One strength of this study is the novelty of comparing patients diagnosed

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Activity on the Ward After ICU

with respiratory failure who underwent twice-daily early physical therapy intervention and mobility guided
by protocol during ICU treatment
with themselves on the ward after
ICU transfer. Limitations of this study
include lack of data regarding why
activity was not recorded, not done,
or done at a lower level on the ward.
Another limitation is lack of longitudinal follow-up to determine longterm effects (benefits) of activity on
patient outcomes. These findings
may not generalize to hospitals that
do not embrace the early ICU mobility approach, perhaps instead placing emphasis on increasing activity
on the wards. The long-term benefits
of early physical therapy intervention and mobilization are just beginning to be investigated. For instance,
a recent study showed patients who
underwent early ICU mobility during
their ICU stay had lower ICU readmission rates during the first year
post-ICU discharge compared with
patients who received usual care.11
These findings suggest that early
mobility may convey long-term benefits in ICU survivors. A final limitation is that our data may not be applicable to patients with critical illness
who are discharged to other settings
such as a long-term care facility.

Dr Hopkins, Dr Miller, Ms Spuhler, and Dr

Thomsen provided concept/idea/research
design. Dr Hopkins, Dr Miller, and Dr Thomsen provided writing. Ms Rodriguez provided data collection. Dr Hopkins, Dr Miller,
Ms Rodriguez, and Dr Thomsen provided
data analysis. Dr Thomsen provided participants. Dr Miller provided institutional liaisons. Dr Miller and Ms Rodriguez provided
clerical support. All authors provided consultation (including review of manuscript
before submission).
The authors give special thanks to the respiratory intensive care unit staff who mobilized
these patients; physical therapy staff members Robert Blair and James Jewkes; and
nurses Polly Bailey, APRN, Louise Bezdjian,
APRN, and Kristy Veal, RN, for their contributions to development, implementation,
and application of the early activity protocol.
An oral presentation of the data, in part,
presented in this article was given at the
Fourth International Meeting of Physical
Medicine and Rehabilitation in the Critically
Ill; May 2011; Denver, Colorado.
There was no outside financial support for
this study.

Conclusions
The majority of patients had a
request for a physical therapy consultation or for nursing assistance
with ambulation at the time of transfer to the medical ward. Physical
activity levels decreased in 55% of
the patients on the first full day on
the ward. We postulate a need for
education of ward staff regarding
ICU debilitation, enhanced communication of physical activity performance between care providers at
time of patient handoff, and a focus

December 2012

on the importance of a patientcentered outcome such as mobility

during and following ICU treatment.
Controlled studies are needed to
determine whether early physical
therapy intervention and mobility
prevent or remediate long-term
neuromuscular dysfunction and other
important functional outcomes that
follow critical illness.

DOI: 10.2522/ptj.20110446

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