Objective: To develop evidence-based recommendations for effective and safe diagnostic assessment and intervention strategies for the physiotherapy treatment of patients in intensive care units. Methods: We used the EBRO method, as recommended by the ‘Dutch Evidence Based Guideline Development Platform’ to develop an ‘evidence statement for physiotherapy in the intensive care unit’. This method consists of the identification of clinically relevant questions, followed by a systematic literature search, and summary of the evidence with final recommendations being moderated by feedback from experts. Results: Three relevant clinical domains were identified by experts: criteria to initiate treatment; measures to assess patients; evidence for effectiveness of treatments. In a systematic literature search, 129 relevant studies were identified and assessed for methodological quality and classified according to the level of evidence. The final evidence statement consisted of recommendations on eight absolute and four relative contra-indications to mobilization; a core set of nine specific instruments to assess impairments and activity restrictions; and six passive and four active effective interventions, with advice on (a) physiological measures to observe during treatment (with stopping criteria) and (b) what to record after the treatment. Conclusions: These recommendations form a protocol for treating people in an intensive care unit, based on best available evidence in mid-2014.

Introduction: ICU-acquired weakness is thought to mediate physical impairments in survivors of critical illness, but few studies have investigated this thoroughly. The purpose was to investigate differences in post-ICU mortality and physical functioning between patients with and without ICU-acquired weakness at 6 months after ICU discharge. Method: ICU patients, mechanically ventilated ≥2 days, were included in a single-center prospective observational cohort study. ICU-acquired weakness was diagnosed when the average Medical Research Council score was <4 in awake and attentive patients. Post-ICU mortality was recorded until 6 months after ICU discharge; in surviving patients, physical functioning was assessed using the Short-Form Health Survey physical functioning domain. The independent effect of ICU-acquired weakness on post-ICU mortality was analyzed using a multivariable Cox proportional hazards model. The independent effect of ICU-acquired weakness on the physical functioning domain score was analyzed using a multivariable linear regression model. Results: Of the 156 patients included, 80 had ICU-acquired weakness. Twenty-three patients died in the ICU (20 with ICU-acquired weakness); during 6 months follow-up after ICU discharge another 25 patients died (17 with ICU-acquired weakness). Physical functioning domain scores were available for 96 survivors (39 patients with ICU-acquired weakness). ICU-acquired weakness was independently associated with an increase in post-ICU mortality (hazard ratio 3.6, 95% confidence interval, 1.3 to 9.8; P = 0.01) and with a decrease in physical functioning (β: -16.7 points; 95% confidence interval, -30.2 to -3.1; P = 0.02). Conclusion: ICU-acquired weakness is independently associated with higher post-ICU mortality and with clinically relevant lower physical functioning in survivors at 6 months after ICU discharge.

The study objective was to obtain consensus on physical therapy (PT) in the rehabilitation of critical illness survivors after hospital discharge. Research questions were: what are PT goals, what are recommended measurement tools, and what constitutes an optimal PT intervention for survivors of critical illness? A Delphi consensus study was conducted. Panelists were included based on relevant fields of expertise, years of clinical experience, and publication record. A literature review determined five themes, forming the basis for Delphi round one, which was aimed at generating ideas. Statements were drafted and ranked on a 5-point Likert scale in two additional rounds with the objective to reach consensus. Results were expressed as median and semi-interquartile range, with the consensus threshold set at ≤0.5. Ten internationally established researchers and clinicians participated in this Delphi panel, with a response rate of 80 %, 100 %, and 100 % across three rounds. Consensus was reached on 88.5 % of the statements, resulting in a framework for PT after hospital discharge. Essential handover information should include information on 15 parameters. A core set of outcomes should test exercise capacity, skeletal muscle strength, function in activities of daily living, mobility, quality of life, and pain. PT interventions should include functional exercises, circuit and endurance training, strengthening exercises for limb and respiratory muscles, education on recovery, and a nutritional component. Screening tools to identify impairments in other health domains and referral to specialists are proposed. A consensus-based framework for optimal PT after hospital discharge is proposed. Future research should focus on feasibility testing of this framework, developing risk stratification tools and validating core outcome measures for ICU survivors.

To evaluate the functional status of patients within the first week of discharge from an intensive care unit (ICU), and to identify predictors and explanatory factors of functional status. A prospective, observational, cohort study was conducted with consecutive ICU patients who had stayed in a mixed, closed-format, university-level ICU for longer than 48 h. Between 3 and 7 days of discharge from the ICU, functional status (as primary outcome), walking ability, muscle strength, and sensory and cognitive functioning were assessed in 69 survivors. The overall functional status was poor (median Barthel Index 6). In their ability to perform basic activities of daily living, 67% percent were severely dependent, 15% were moderately dependent, and 9% were slightly dependent on other people. Independent walking was impossible for 73% of participants, grip strength was reduced for 50%, and 30% had cognitive impairments. Duration of ventilation was associated with functional status after ICU discharge. Reduced grip strength and walking ability were identified as explanatory factors for poorer functional status shortly after discharge from the ICU. In the first week after discharge from the ICU, the majority of the patients had substantial functional disabilities in activities of daily living. These disabilities were more severe in patients who experienced ventilation for a longer period of time. There is a need for prospective studies focusing on functional recovery to support informed decision-making concerning the care of critically ill patients after ICU discharge.

Journal of Rehabilitation Medicine is an international peer-review journal published in English, with at least 10 issues published per year.

To determine the time course of functional health status, and to inventory impairments in body functions, limitations in activities, and restrictions in participation after critical illness. Prospective observational cohort study. Mixed medical and surgical closed format; intensive care unit of an academic medical hospital. Consecutive patients over a period of 3 months who were ventilated in the intensive care unit for more than 48 h (n = 116). Functional health status was assessed 3, 6 and 12 months after discharge from the intensive care unit using the Sickness Impact Profile 68. Impairments in function, limitations in activities, and restrictions in participation, classified according to the International Classification of Functioning, Disability, and Health (ICF), were evaluated after 3 and 12 months. Due to a high mortality rate (48%) and poor health conditions, data could not be obtained from all participants at all measurement points. Physical functioning and social behaviour improved predominantly within the first 6 months, while impaired psychological functioning remained unchanged within one year after discharge from the intensive care unit. After one year, 69% of patients were still restricted in performing daily activities and only 50% had resumed work. The extent and severity of lasting intensive care unit-related disability necessitates the development of multidisciplinary after-care to improve health status, functional independence and return to work.