Original research| Volume 100, ISSUE 2, P261-269.e2, February 2019

Commencing Out-of-Bed Rehabilitation in Critical Care—What Influences Clinical Decision-Making?

Published:August 30, 2018DOI:


      • Out-of-bed rehabilitation was prescribed despite no evidence of strength deficits.
      • Patients met safety criteria, had weakness but did not receive rehabilitation.
      • At the point of care endotracheal tube and sedation are barriers to rehabilitation.
      • Identifying rehabilitation responders is needed to harmonize clinical decision-making.



      To develop a decision tree that objectively identifies the most discriminative variables in the decision to provide out-of-bed rehabilitation, measure the effect of this decision and to identify the factors that intensive care unit (ICU) practitioners think most influential in that clinical decision.


      A prospective 3-part study: (1) consensus identification of influential factors in mobilization via survey; (2) development of an early rehabilitation decision tree; (3) measurement of practitioner mobilization decision-making. Treating practitioners of patients expected to stay >96 hours were asked if they would provide out-of-bed rehabilitation and rank factors that influenced this decision from an a priori defined list developed from a literature review and expert consultation.


      Four tertiary metropolitan ICUs.


      Practitioners (ICU medical, nursing, and physiotherapy staff) (N=507).


      Not applicable.

      Main Outcome Measures

      A decision tree was constructed using binary recursive partitioning to determine the factor that best classified patients suitable for out-of-bed rehabilitation. Descriptive statistics were used to describe practitioner and patient samples as well as patient adverse events associated with out-of-bed rehabilitation and the factors prioritized by ICU practitioners.


      There were 1520 practitioner decisions representing 472 individual patient decisions. Practitioners classified patients suitable for out-of-bed rehabilitation on 149 occasions and not suitable on 323 occasions. Decision tree analysis showed the presence of an endotracheal tube (ETT) and sedation state were the only discriminative variables that predicted patient suitability for rehabilitation. In contrast, medical staff and nurses reported that ventilator status was the most influential factor in their decision not to provide rehabilitation while physiotherapists ranked sedation most highly. The presence of muscle weakness did not inform the decision to provide rehabilitation.


      These results confirm previous observational reports that the presence of an ETT remains a major obstacle to the provision of rehabilitation for critically ill patients. Despite rehabilitation being effective for improving muscle strength, the presence of muscle weakness did not influence the decision to provide rehabilitation.


      List of abbreviations:

      ETT (endotracheal tube), Fio2 (fraction of inspired oxygen), ICU (intensive care unit), ICU-AW (intensive care unit–acquired weakness), Pao2 (partial pressure of oxygen dissolved in blood), RASS (Richmond Agitation and Sedation Scale)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Fan E.
        • Dowdy D.W.
        • Colantuoni E.
        • et al.
        Physical complications in acute lung injury survivors: a two-year longitudinal prospective study.
        Crit Care Med. 2014; 42: 849-859
        • Hermans G.
        • Van Mechelen H.
        • Clerckx B.
        • et al.
        Acute outcomes and 1-year mortality of intensive care unit-acquired weakness. A cohort study and propensity-matched analysis.
        Am J Respir Crit Care Med. 2014; 190: 410-420
        • Denehy L.
        • Lanphere J.
        • Needham D.M.
        Ten reasons why ICU patients should be mobilized early.
        Intensive Care Med. 2017; 43: 86-90
        • Tipping C.J.
        • Harrold M.
        • Holland A.
        • Romero L.
        • Nisbet T.
        • Hodgson C.L.
        The effects of active mobilisation and rehabilitation in ICU on mortality and function: a systematic review.
        Intensive Care Med. 2017; 43: 171-183
      1. Society of Critical Care.
        (Available at:) (Accessed February 24, 2017)
        • Girard T.D.
        • Alhazzani W.
        • Kress J.P.
        • et al.
        An official american thoracic society/american college of chest physicians clinical practice guideline: liberation from mechanical ventilation in critically ill adults. Rehabilitation protocols, ventilator liberation protocols, and cuff leak tests.
        Am J Respir Crit Care Med. 2017; 195: 120-133
        • Nydahl P.
        • Sricharoenchai T.
        • Chandra S.
        • et al.
        Safety of patient mobilization and rehabilitation in the ICU: systematic review with meta-analysis.
        Ann Am Thorac Soc. 2017; 14: 766-777
        • Hodgson C.L.
        • Stiller K.
        • Needham D.M.
        • et al.
        Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults.
        Crit Care. 2014; 18: 658
        • Hodgson C.
        • Bellomo R.
        • et al.
        • TEAM Study Investigators
        Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study.
        Crit Care. 2015; 19: 81
        • Berney S.C.
        • Rose J.W.
        • Bernhardt J.
        • Denehy L.
        Prospective observation of physical activity in critically ill patients who were intubated for more than 48 hours.
        J Crit Care. 2015; 30: 658-663
        • Berney S.
        • Harrold M.
        • Webb S.
        • et al.
        Intensive care unit mobility practices in Australia and New Zealand: a point prevalence study.
        Crit Care Resusc. 2013; 15: 260-265
        • Jolley S.E.
        • Moss M.
        • Needham D.M.
        • et al.
        Point prevalence study of mobilization practices for acute respiratory failure patients in the United States.
        Crit Care Med. 2017; 45: 205-215
        • Nydahl P.
        • Ruhl A.P.
        • Bartoszek G.
        • et al.
        Early mobilization of mechanically ventilated patients: a 1-day point-prevalence study in Germany.
        Crit Care Med. 2014; 42: 1178-1186
        • Sibilla A.
        • Nydahl P.
        • Greco N.
        • et al.
        Mobilization of mechanically ventilated patients in Switzerland.
        J Intensive Care Med. 2017; (885066617728486)
        • Barber E.A.
        • Everard T.
        • Holland A.E.
        • Tipping C.
        • Bradley S.J.
        • Hodgson C.L.
        Barriers and facilitators to early mobilisation in intensive care: a qualitative study.
        Aust Crit Care. 2015; 28 (quiz 183): 177-182
        • Dubb R.
        • Nydahl P.
        • Hermes C.
        • et al.
        Barriers and strategies for early mobilization of patients in intensive care units.
        Ann Am Thorac Soc. 2016; 13: 724-730
        • Holdsworth C.
        • Haines K.J.
        • Francis J.J.
        • Marshall A.
        • O'Connor D.
        • Skinner E.
        Mobilization of ventilated patients in intensive care unit: an eliciation study using the theory of planned behavior.
        J Crit Care. 2015; 30: 1243-1250
        • Leditschke I.A.
        • Green M.
        • Irvine J.
        • Bissett B.
        • Mitchell I.A.
        What are the barriers to mobilizing intensive care patients?.
        Cardiopulm Phys Ther J. 2012; 23: 26-29
        • Parry S.M.
        • Knight L.D.
        • Connolly B.
        • et al.
        Factors influencing physical activity and rehabilitation in survivors of critical illness: a systematic review of quantitative and qualitative studies.
        Intensive Care Med. 2017; 43: 531-542
        • Vandenbroucke J.P.
        • von Elm E.
        • Altman D.G.
        • et al.
        Strengthening the reporting of observational studies in epidemiology (STROBE): explanation and elaboration.
        Epidemiology. 2007; 18: 805-835
        • Skinner E.
        • Warrillow S.
        • Denehy L.
        Organisation and resource management in the intensive care unit: a critical review.
        Int J Ther Rehabil. 2015; 22: 187
        • Morandi A.
        • Brummel N.E.
        • Ely E.W.
        Sedation, delirium and mechanical ventilation: the 'ABCDE' approach.
        Curr Opin Crit Care. 2011; 17: 43-49
        • Breiman L.
        • Friedman J.H.
        • Olsen R.A.
        • Stone C.J.
        Classification and regression trees.
        Chapman and Hall, New York1984
        • Viera A.J.
        • Garrett J.M.
        Understanding interobserver agreement: the kappa statistic.
        Fam Med. 2005; 37: 360-363
        • Morris P.E.
        • Berry M.J.
        • Files D.C.
        • et al.
        Standardized rehabilitation and hospital length of stay among patients with acute respiratory failure: a randomized clinical trial.
        JAMA. 2016; 315: 2694-2702
        • Reade M.C.
        • Finfer S.
        Sedation and delirium in the intensive care unit.
        N Engl J Med. 2014; 370: 444-454
        • Herridge M.S.
        • Chu L.M.
        • Matte A.
        • et al.
        The recover program: disability risk groups and 1-year outcome after 7 or more days of mechanical ventilation.
        Am J Respir Crit Care Med. 2016; 194: 831-844
        • Denehy L.
        • Skinner E.H.
        • Edbrooke L.
        • et al.
        Exercise rehabilitation for patients with critical illness: a randomized controlled trial with 12 months of follow-up.
        Crit Care. 2013; 17: R156
        • Moss M.
        • Nordon-Craft A.
        • Malone D.
        • et al.
        A randomized trial of an intensive physical therapy program for patients with acute respiratory failure.
        Am J Respir Crit Care Med. 2016; 193: 1101-1110
        • Prescott H.C.
        • Calfee C.S.
        • Thompson B.T.
        • Angus D.C.
        • Liu V.X.
        Toward smarter lumping and smarter splitting: Rethinking strategies for sepsis and acute respiratory distress syndrome clinical trial design.
        Am J Respir Crit Care Med. 2016; 194: 147-155
        • Puthucheary Z.A.
        • Denehy L.
        Exercise interventions in critical illness survivors: understanding inclusion and stratification criteria.
        Am J Respir Crit Care Med. 2015; 191: 1464-1467
        • Heyland D.K.
        • Stapleton R.D.
        • Mourtzakis M.
        • et al.
        Combining nutrition and exercise to optimize survival and recovery from critical illness: conceptual and methodological issues.
        Clin Nutr. 2016; 35: 1196-1206
        • Blackwood B.
        • Marshall J.
        • Rose L.
        Progress on core outcome sets for critical care research.
        Curr Opin Crit Care. 2015; 21: 439-444


        • Stiller K.
        • Phillips A.
        • Lambert P.
        The safety of mobilisation and its effect on haemodynamic and respiratory status of intensive care patients.
        Physiotherapy Theory Practice. 2004; 20: 175-185
        • Bailey P.
        • Thomsen G.E.
        • Spuhler V.J.
        • et al.
        Early activity is feasible and safe in respiratory failure patients.
        Crit Care Med. 2007; 35: 139-145
        • Morris P.E.
        • Goad A.
        • Thompson C.
        • et al.
        Early intensive care unit mobility therapy in the treatment of acute respiratory failure.
        Crit Care Med. 2008; 36: 2238-2243
        • Thomsen G.E.
        • Snow G.L.
        • Rodriguez L.
        • Hopkins R.O.
        Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority.
        Crit Care Med. 2008; 36: 1119-1124
        • Burtin C.
        • Clerckx B.
        • Robbeets C.
        • et al.
        Early exercise in critically ill patients enhances short-term functional recovery.
        Crit Care Med. 2009; 37: 2499-2505
        • Schweickert W.D.
        • Pohlman M.C.
        • Pohlman A.S.
        • et al.
        Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial.
        Lancet. 2009; 373: 1874-1882
        • 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: 400-407
        • Needham D.M.
        • Korupolu R.
        • Zanni J.M.
        • et al.
        Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project.
        Arch Phys Med Rehabil. 2010; 91: 536-542
        • Zanni J.M.
        • Korupolu R.
        • Fan E.
        • et al.
        Rehabilitation therapy and outcomes in acute respiratory failure: an observational pilot project.
        J Crit Care. 2010; 25: 254-262
        • Pohlman M.C.
        • Schweickert W.D.
        • Pohlman A.S.
        • et al.
        Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation.
        Crit Care Med. 2010; 38: 2089-2094
        • Berney S.
        • Haines K.
        • Skinner E.H.
        • Denehy L.
        Safety and feasibility of an exercise prescription approach to rehabilitation across the continuum of care for survivors of critical illness.
        Phys Ther. 2012; 92: 1524-1535
        • Brummel N.E.
        • Jackson J.C.
        • Girard T.D.
        • et al.
        A combined early cognitive and physical rehabilitation program for people who are critically ill: the activity and cognitive therapy in the intensive care unit (ACT-ICU) trial.
        Phys Ther. 2012; 92: 1580-1592
        • Kho M.E.
        • Damluji A.
        • Zanni J.M.
        • Needham D.M.
        Feasibility and observed safety of interactive video games for physical rehabilitation in the intensive care unit: a case series.
        J Crit Care. 2012; 27: 219
        • Kho M.E.
        • Truong A.D.
        • Brower R.G.
        • et al.
        Neuromuscular electrical stimulation for intensive care unit-acquired weakness: protocol and methodological implications for a randomized, sham-controlled, phase II trial.
        Phys Ther. 2012; 92: 1564-1579
        • Clark D.E.
        • Lowman J.D.
        • Griffin R.L.
        • Matthews H.M.
        • Reiff D.A.
        Effectiveness of an early mobilization protocol in a trauma and burns intensive care unit: a retrospective cohort study.
        Phys Ther. 2013; 93: 186-196
        • Denehy L.
        • Skinner E.H.
        • Edbrooke L.
        • et al.
        Exercise rehabilitation for patients with critical illness: a randomized controlled trial with 12 months of follow-up.
        Crit Care. 2013; 17: R156
        • Drolet A.
        • DeJuilio P.
        • Harkless S.
        • et al.
        Move to improve: the feasibility of using an early mobility protocol to increase ambulation in the intensive and intermediate care settings.
        Phys Ther. 2013; 93: 197-207
        • Engel H.J.
        • Tatebe S.
        • Alonzo P.B.
        • Mustille R.L.
        • Rivera M.J.
        Physical therapist-established intensive care unit early mobilization program: Quality improvement project for critical care at the University of California San Francisco Medical Center.
        Phys Ther. 2013; 93: 975-985
        • Rahimi R.A.
        • Skrzat J.
        • Reddy D.R.
        • et al.
        Physical rehabilitation of patients in the intensive care unit requiring extracorporeal membrane oxygenation: a small case series.
        Phys Ther. 2013; 93: 248-255
        • Talley C.L.
        • Wonnacott R.O.
        • Schuette J.K.
        • Jamieson J.
        • Heung M.
        Extending the benefits of early mobility to critically ill patients undergoing continuous renal replacement therapy: the michigan experience.
        Crit Care Nurs Q. 2013; 36: 89-100