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Cardiopulmonary
Physical Therapy
Journal
Volume 23 Number 1 March 2012
Special issue:
physical therapy IN Critical Care
Official Journal of the Cardiovascular & Pulmonary Section

American Physical Therapy Association
Cardiopulmonary Physical Therapy Journal
Official Journal of the Cardiovascular & Pulmonary Section

Editor-in-Chief
Anne K. Swisher, PT, PhD, CCS
West Virginia University
Table of Contents
Features Editor
Susan Scherer, PT, PhD
Regis University
4 Guest Editorial: Physical Therapy in Critical

Care

Susan Scherer
Consulting Editor
Gerald R. Hobbs, PhD
Associate Editors
Sean Collins, PT, ScD
University of Massachusetts at Lowell
W. Darlene Reid BMR (PT), PhD
University of British Columbia
Editorial Board
Jennifer Alison, PT, PhD
University of Sydney
5 Early Mobilization in the Intensive Care Unit:

A Systematic Review
Joseph Adler, Daniel Malone
14 Respiratory and Hemodynamic Responses to
Mobilization of Critically Ill Obese Patients
Arzu Genc, Seher Ozyurek, Ugur Koca,
Ali Gunerli
19 Physiotherapy in Critical Care in Australia
Susan Berney, Kimberley Haines, Linda Denehy
Lawrence Cahalin, MA, PT, CCS

University of Miami
26 What are the Barriers to Mobilizing Intensive

Care Patients?
I Anne Leditschke, Margot Green, Joelie Irvine,
Bernie Bissett, Imogen A Mitchell
Sandra Cassady, PT, PhD, FAACVPR

St. Ambrose University
Joseph Norman, PT, PhD, CCS
University of Nebraska
Jane Schneiderman, CEP MS (ExSci)
Hospital for Sick Children, Toronto, Ont
Advertising & Subscriptions

Copyright 2012 (ISSN 1541-7891) by the Cardiovascular
and Pulmonary Section, APTA. Opinions expressed by the
authors are their own and do not necessarily reflect the
views of the Cardiovascular and Pulmonary Section. The
Editor reserves the right to edit manuscripts as necessary for
publication. The Cardiopulmonary Physical Therapy Journal
is indexed by the National Library of Medicine (PubMed
Central), the Cumulative Index to Nursing and Allied Health
Literature (CINAHL), EBSCO Research Databases, and the
Thomson Gale Databases (Academic One File).
30 Physical Therapy Management of a Patient

on Portable Extracorporeal Membrane
Oxygenation as a Bridge to Lung Transplation:
A Case Report

John D. Lowman, Tamara K, Kirk, Diane E. Clark
36 Using Simulation and Patient Role Play to
Teach Electrocardiographic Rhythms to Physical
Therapy Students
Nancy Smith, Sharon Prybylo, Teresa Conner-Kerr
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Editorial
Guest Editorial: Physical Therapy in Critical Care
The role of physical therapists in critical care has been
evolving. Of interest to this section, traditional PT care in
the ICU focused on interventions for respiratory conditions,
using techniques such as percussion, manual hyperinflation, suctioning, and bed exercises. As our knowledge of
the importance of early mobilization has evolved, as evidenced by changes in how quickly patients are out of bed
following cardiac surgery, the interventions in physical
therapy have changed. The physiologic rationale for early
mobilization has been discussed since the early 1990s in
papers written in part by leaders in cardiovascular and pulmonary physical therapy.1 What has been lacking is strong
evidence of the benefits of early mobilization in critically
ill patients. In the past few years, the number of poster
and platform sessions at the Combined Sections Meetings
focused on physical therapy in critically ill patients has increased. Similarly, the number of published articles on this
topic is growing.
The topic for this special issue developed in response
to these trends. Our call for papers resulted in a variety of
manuscripts. We have a systematic review of mobilization
in the ICU, which focuses on both safety and effectiveness
outcomes. There is good evidence to support the effectiveness of early mobilization, even in patients on mechanical
ventilation. Several interesting case examples are included
that will be very useful in helping clinicians determine the
types of interventions and outcomes most relevant to treating patients in ICU environments. One paper also addresses
what can be done in the academic environment to prepare
students for work in these complex practice environments.
And, we benefit from the expertise of our colleagues in other countries; in this edition, we have examples from Turkey
and Australia as well as the United States.
The articles chosen for this issue illustrate several treatment trends that will help advance the work of PT in the
critical care environment. One of our articles discusses the
barriers to treatment of patients in the ICU. This shows us
that some barriers, such as timing of medication administration, could be easily addressed, but will require the physical
therapist to be committed to active mobilization of patients
and demonstrate ability to communicate effectively with
other members of the ICU team. Overall, there are relatively
few adverse effects of early mobilization, particularly when
therapists are observing the physiologic response of patients
by monitoring vital signs during treatment sessions. A number of articles discussed in the systematic review provide
guidelines for discontinuing treatment based on vital sign
responses. This reminds us that we need increasing focus on
one of the key tenets of cardiopulmonary physical therapy
practice; that we are treating the patients physiologic deficits
in conjunction with movement and functional abnormalities.
There is much work to be done in advancing the practice of PT in these critical care environments. What an exciting time of practice to be able to shape the interventions
and influence better health outcomes for our patients!
REFERENCE
1. Ross J, Dean E. Integrating physiological principles into
the comprehensive management of cardiopulmonary
dysfunction. Phys Ther. 1989;69(4):255-259.
Susan Scherer, PT, PhD

Associate Editor
Early Mobilization in the Intensive Care Unit:

A Systematic Review
Joseph Adler, PT, DPT, CCS1
Daniel Malone, PhD, MPT, CCS2
Good Shepherd Penn Partners at The Hospital of the University of Pennsylvania, Philadelphia, PA
Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Denver, CO
1
ABSTRACT
Purpose: The purpose of this review is to evaluate the literature related to mobilization of the critically ill patient with
an emphasis on functional outcomes and patient safety.
Methods: We searched the electronic databases of PubMed,
CINAHL, Medline (Ovid), and The Cochrane Library for a
period spanning 2000-2011. Articles used in this review included randomized and nonrandomized clinical trials, prospective and retrospective analyses, and case series in peerreviewed journals. Sacketts Levels of Evidence were used
to classify the current literature to evaluate the strength of
the outcomes reported. Results: Fifteen studies met inclusion criteria and were reviewed. According to Sacketts
Levels of Evidence, 9 studies were level 4 evidence, one
study was level 3, 4 studies were level 2, and one study was
level one evidence. Ten studies pertained to patient safety/
feasibility and 10 studies pertained to functional outcomes
with 5 fitting into both categories. Conclusion: A search of
the scientific literature revealed a limited number of studies
that examined the mobilization of critically ill patients in
the intensive care unit. However, literature that does exist
supports early mobilization and physical therapy as a safe
and effective intervention that can have a significant impact
on functional outcomes.
Key Words: mobilization, exercise, intensive care unit, critical illness, physical therapy
INTRODUCTION
The early mobilization of patients in the intensive care
unit (ICU) has received considerable attention in clinical and scientific literature over the past several years.1-3
A wide range of published reports has attempted to study
the effects of mobilization and physical therapy on multiple factors including patient safety, ambulation capacity,
Address correspondences to: Joe Adler, PT, DPT, CCS,

Good Shepherd Penn Partners at the Hospital of the
University of Pennsylvania, Department of Occupational and Physical Therapy, 1st Floor White Building, 3400 Spruce Street, Philadelphia, PA 19104 (joe.
adler@uphs.upenn.edu).
muscle strength, functional outcomes such as activities of

daily living, duration of mechanical ventilation, ICU length
of stay, hospital length of stay, and mortality.
There are inherent complications to mobilizing critically ill patients that appear straightforward but are not well
established. These apparent complications include, but are
not limited to: tenuous hemodynamic status, severe weakness, multiple central catheters and life supporting monitors, artificial airways and operational factors such as variable rehabilitation work practices.4-7
Studies have demonstrated that survivors of critical illness have impaired exercise capacity and persistent weakness, suboptimal quality of life, enduring neuropsychological impairments and high costs of health care utilization.8-12
It has been hypothesized that ICU-based interventions may
play a role in reducing these ongoing physical and neuropsychological impairments in ICU survivors in both the
short- and long-term, highlighting the importance of studying this population.12
When patients require admission or readmission to the
ICU, a period of enforced bed rest generally ensues. Despite
knowledge of the deleterious effects of bed rest on multiple
body systems,13-16 the ICU is a complicated and difficult
environment in which to mobilize the critically ill.1,17 Multiple life-sustaining catheters and monitors, sedative medication used to calm agitation or reduce energy expenditure,
impaired levels of alertness from medications, sleep disturbances, electrolyte imbalances, and tenuous hemodynamic
status all are contributing factors that limit mobilization.
As critical care medicine improves and overall mortality decreases, survivors of ICU admissions are realizing
greater morbidity. Severe weakness, deficits in self-care
and ambulation, poor quality of life, hospital readmission,
and death have all been reported in patients up to 5 years
after discharge from the ICU.12,18
Mobilizing patients in the intensive care environment
is not without risk. Catheters and supportive equipment attached to patients can become dislodged and cause injury.
Insertion and reinsertion of catheters can increase infection
risk and cause unwanted stress and pain for patients and
families already stressed by the medical acuity of the ICU.
Critically ill patients with physiological derangements can
have adverse hemodynamic responses to activity. Patients
with limited aerobic capacity may respond to exertional
stress with exaggerated heart rate and blood pressure responses or conversely may not have enough physiologic
reserve to meet even the seemingly simple task of sitting on
the edge of the bed.
Although the frequency of published reports related to
mobilizing critically ill patients is increasing, the number
of controlled, randomized trials is few. The purpose of this
review was to examine the literature and characterize the
clinical benefits of mobilizing critically ill patients found
predominantly in the ICU, specifically related to safety and
functional outcomes.
METHODS
Literature Search
The electronic databases of PubMed, CINAHL/Nursing,
Medline (Ovid) and the Cochrane Library were searched
as noted in Figure 1. The key search terms, mobilization,
exercise, and physical therapy were combined with
intensive care unit and critical illness. Reference lists of
review articles and original publications were manually reviewed supplementing the electronic search to ensure that
the database searches were comprehensive.
Study Selection Criteria
Articles included in this review were: prospective randomized trials, prospective cohort studies, retrospective
analyses, and case series. We further limited our inclusion
to articles that focused on adults that were published in
English between January 1, 2000 and June 1, 2011 to capture the most recently published work. Studies were evaluated to determine fit to the inclusion criteria by review of
the title, and the list of potential articles was further sorted
by reviewing abstracts by the primary author (JA). Studies
were excluded if they were review articles, only studied
nonmobility interventions, and/or described programs or
protocols designed to promote early mobilization. If relevancy was questioned, both authors then collaborated on
the final decision for inclusion.
Levels of Evidence
Sacketts Levels of Evidence were used to rate the
strength of the research19 process where research was
ranked from strongest to weakest using a 5 point grading
system as outlined in Table 1. The authors (DM and JA) collaborated equally on scoring.
Table 1. Sacketts Levels of Evidence
1A
Systematic Review of Randomized Controlled Trials (RCTs)
1B
RCTs with Narrow Confidence Interval
1C
All or None Case Series
2A
Systematic Review Cohort Studies
2B
Cohort Study/Low Quality RCT
2C
Outcomes Research
3A
Systematic Review of Case-Controlled Studies
3B
Case-controlled Study
Case Series, Poor Cohort Case Controlled
Expert Opinion
Adapted from Levels of Evidence. Oxford Centre for Evivdence-based Medicine - Levels of
Evidence (March 2009) Website. Available at www.cebm.net. Accessed September 26, 2011.
RESULTS
Fifteen studies were included in
this review and submitted to analysis.
Many outcomes were reported in the
mobilization of critically ill patients
and included a wide range of data.
The studies were categorized into
two groups based on the outcome
addressed: safety and functional outcomes. Functional outcomes were
further subdivided into one of 3 areas:
muscle strength; quality of life/patient
symptoms, and mobility. Some studies overlapped multiple categories. Of
the studies reviewed, 4 reported on
muscle strength, two on quality of life,
and 13 on functional mobility.
Studies included both prospective
and retrospective design while randomization occurred in just 3 studies.20-22 The randomization in Chiang
et als study22 occurred in a postintensive care environment. Ten studies examined cohort populations or samples
of convenience. Eleven of those were
prospective.4,20-29 Four studies were
Figure 1. Search algorithm.
Table 2. Safety and ICU Mobilization

Study
Study Design
(N= subjects)
Sacketts
Levels of
Evidence
Physical Therapy
Interventions
Safety profile
Other notable findings
Stiller K. 200427
Prospective
Functional mobility

Supine-to-sit

Sitting edge of bed

Standing

Transfers

Ambulation
69 mobilization sessions with 31 patients

(MV = 7 patients (23%)):
3 events (4%) during PT treatments (2

patients on MV)

desaturation ( 88%) responsive to
increased FIO2
Overall, no serious adverse medical
consequences
One-group pretest-posttest design

N= 160 total patients with 31
receiving mobilization
Zafiropoulos B.
200429
Prospective

N=17
Patients participated in
progressive mobilization
from supine> sitting>
standing> marching x 1
minute for each activity
Bailey P. 200723
Prospective

N=103 patients
Twice daily PT/ activity

sessions
Functional Mobility

Supine-to-sit

Sitting edge of bed

Standing

Transfers

Ambulation
FIO2 was increase 0.2 prior
to sessions
Morris PE. 200825
Prospective
14 events (<1%) occurred during PT

sessions:

falls to knees (x5)

desaturation < 80% (x3)

SBP <90 mm (x4)

SBP> 200 mmHg (x1)

Nasogastric tube removal (x1)
consequences
425 total exercise sessions

16 sessions (<4%) terminated due to
desaturation <90% or HTN;

3 subjects withdrawn:

Achilles tendon rupture (x1)

cardiorespiratory instability
(x2)
Achilles tendon rupture could be considered a

serious adverse event

injury most likely due to the addition of
cycling as a treatment modality

cardio-respiratory instability not well
defined in paper.
1B
7 days/ week
Treatment group:
Progressive UE/ LE ther
ex.; Trunk control/ balance
activities
Functional training including
ADLs
498 PT/ OT sessions:

1 desaturation <80%

1 radial artery line removed

PT/ OT was discontinued during 19
sessions (4%) for perceived patientventilator asynchrony
Overall, no adverse medical consequences
As noted above
In patients receiving MV, the primary

reasons for missed therapy session

MV asynchrony (<4%)

MAP <65 mm Hg (<1%)

Vasoactive medication (<1%)

Active GIB (<1%)
Descriptive study/ case series

using data from prior study (see
Schweickert above)
N= 49 patients
PT/ OT sessions were terminated due to

Desaturation >5% (6%)

HR & MV asynchrony (4%)

Agitation/ discomfort (2%)

Device/ line removal (<1%)
Zanni JM.
20104
Prospective
Pilot Project
(N= 32 eligible; 22 completed
study to hospital discharge)
Study provides systems review criteria

(neurologic/ circulatory/ respiratory) used
to screen patients prior to mobilization
Of the approximate 1500 activities
performed:

Sit at edge of bed (16%)

OOB (31%)

Ambulate (53%)
Age & co morbidities did not influence
ambulatory status
5 days/ week
Both groups received:
Upper extremity ther. ex.
Lower extremity ther
ex. Functional training.
Treatment group: Additional
cycling session x 20 minutes
total, daily
(N=104; all patients completed

study)
Retrospective
1449 PT/ activity sessions:
2B
RCT
Pohlman MC.
201032
(N = 90 enrolled; 67 completed)
(36 control; 31 treatment group)
Prospective
116 of 135 patients (80%) of

protocol patients received PT during
hospital stay for approx. 638 total PT
sessions

Therapy sessions not initiated if
BP/ HR outside of listed inclusion
criteria ( 1.4% of total sessions)
consequences
RCT
Schweickert WD.
200920
(N=330; 165 intervention/

protocol; 165 usual care)
Prospective
Study emphasized the hemodynamic and

respiratory responses in patients who were
s/p abdominal surgery

Included measurements of chest
wall and abdominal movements to
characterize the breathing pattern
No hemodynamic or respiratory
compromise
Altered breathing pattern favored upper
chest breathing/ ventilation
Pain was not monitored
No control group for comparison
Mobilization program
implemented 7 days/
week by mobility team
consisting of:
PT
Critical care RN
Nursing assistant
2B
Cohort study
Burtin C. 200921
Minute ventilation increased

due to increases in tidal volume
& respiratory rate with standing
with no additional increase with
marching; the breathing pattern
demonstrated greater upper chest
versus abdominal excursion
ABG values were normal
HR/ BP/ MAP increased with
mobilization from supine> sitting
Study highlights the physiologic responses

(HR, BP, SpO2) and patient safety
associated with mobilization
Paper reintroduces an algorithm for safe
patient handling pertaining to the acute
care/ ICU settings
Only 31 of 160 of patients (19%) were
mobilized following the screening process
Observational report to
define patient profiles and
therapy services in ICU:

consult & treatment
frequency

mobility/ ADLs

ROM/ strength

patient safety
50 reviewed PT/ OT session with 19

patients
consequences
Protocol for mobilization(activity

algorithm) and criteria for limiting therapy
sessions are well defined
Mobility sessions primarily ended due
to patient c/o fatigue without significant
change in vital signs
Protocol for mobilization and criteria for

limiting therapy sessions are well defined
Study supports that early PT/ OT is safe
and the primary event limiting patient
participation in PT/OT was patientventilator asynchrony
Early PT/ OT is feasible & safe within 2448 hours of ICU admission/ MV
PT/OT occurred on 87% of eligible days
(n=498 of 570); # of missed session similar
between MV and extubated patients
Patients performed more aggressive
mobilization as they progressed from MV
to extubation
PT/ OT sessions proceeded even though
patients had central venous access/ HD
catheters; arterial lines; ETT/ tracheostomy
tubes
Following extubation, PT/ OT held
primarily due to patient refusal (c/o fatigue)
Study identified common barriers &
provides helpful recommendations to
implement PT/OT in ICU setting
over half of patients required post-acute
rehabilitation following ICU stay
81% of patients had an episode of delirium
Needham DM.
201026
Prospective
Quality Improvement (QI) project
3B
Case controlled
(N = 57 total (27 pre QI; 30

post QI)
Bourdin G. 2010 28
Prospective
One-group repeated
measurements
Functional mobility
Pre-QI: 210 PT/ OT treatment session
Supine-to-sit
Sitting edge of bed
Standing
Transfers
Ambulation
Increased number of PT/ OT consults &

treatment sessions incorporating more
advanced mobilization activities without
increased incidence of adverse events
Study emphasizes the physiologic

responses associated with a variety of
mobilization procedures
Study determined barriers to rehabilitation
Study determined that early mobilization

was feasible and safe
No events
QI Period: 810 PT/ OT treatment sessions

4 events (rectal or feeding tube

displacement)

consequences
Functional mobility training

(chair sitting; tilting up with
& without arms supported,
ambulation)
424 interventions with 13 events (3%)

loss of muscle tone without fall
extubation; desaturation <88%,

hypotension
N=20 consecutive patients

consequences
Included use of equipment to

facilitate upright/ assisted standing
MV=mechanical ventilation, PT=physical therapy, OT=occupational therapy, FiO2=fraction of inspired oxygen , HR= heart rate, HTN=hypertension
BP=blood pressure, SBP=systolic blood pressure, MAP=mean arterial pressure, SPo2=saturation of peripheral oxygen, ICU=intensive care unit
ABG=arterial blood gas, OOB=out of bed, RN=nurse , s/p=status post, c/o=complains of, RCT=randomized controlled trial, Ther ex.=therapeutic exercise, ROM=range of motion, UE/LE=upper/lower
extremity, ADL=activity of daily living, GIB=gastrointestinal bleed, HD=hemodialysis , ETT=endotracheal tube
retrospective analyses.18,30-32 Two of those studied patients

in a postacute environment.30,31
Safety/Adverse Events
Of all studies reviewed, 10 papers reported data concerning untoward events (eg, line removal, extubation), physiological responses [eg, heart rate (HR), blood pressure (BP), pulse
oximetry] and/or need for alteration in medical plan of care
(eg, sedative or vasopressor administration). The authors (JA
and DM) defined these events as pertaining to patient safety.
As noted in Table 2 untoward events occurred in 4% of
total patient interactions. The reviewed studies used specific
physiologic responses and patient complaints (see Table 3)
to initiate and terminate exercise or activity sessions. Bailey
et al23 consecutively enrolled patients with respiratory failure
who required mechanical ventilation for >4 days. There were

14 activity-associated untoward events during 1,449 activity
sessions, none of which were deemed serious. In the study
by Pohlman and colleagues32 a descriptive analysis of the
intervention arm of the study by Schweickert et al,20 activity associated adverse events occurred in 16% (80 of 498)
of therapy sessions with patients on mechanical ventilation.
The authors describe many of the events as expected physiological changes with exercise. Examples include a HR increase greater than 20% of baseline (21 of 498 or 4.2 %), and
a respiratory rate (RR) greater than 40 breaths per minute (20
of 498 interactions or 4.0%). Activity sessions were halted
due to exceeding the predetermined criteria (see Table 3).
Overall, the most commonly cited adverse event was
oxygen desaturation. These episodes were of short dura-
Table 3. Criteria for Terminating a PT/ OT Mobilization Session as Summarized from the Literature
Heart Rate:
> 70% APMHR
> 20% decrease in resting HR
< 40 beats/ minute; > 130 beats/ minute
New onset dysrhythmia
New anti-arrhythmia medication
New MI by ECG or cardiac enzymes
Pulse Oximetry/ SpO2:

> 4% decrease
< 88%- 90%
Blood Pressure:
SBP > 180 mmHg
> 20% decrease in SPB/ DBP; orthostatic hypotension
MAP < 65 mmHg; >110 mmHg
Presences of vasopressor medication; new vasopressor or escalating
dose of vasopressor medication
Mechanical Ventilation:
FIO2 0.60
PEEP 10
Patient-ventilator asynchrony
MV mode change to assist-control
Tenuous airway
Respiratory Rate:
< 5 breaths/ minute; > 40 breaths/ minute
Alertness/ Agitation and Patient symptoms:

Patient sedation or coma RASS -3
Patient agitation requiring addition or escalation of sedative
medication; RASS >2
Patient c/o intolerable DOE
Patient refusal
PT=physical therapy, OT=occupational therapy, HR= heart rate, RR=respiratory rate

SPo2=saturation of peripheral oxygen, MI=myocardial infarction, ECG=electrocardiogram
BP=blood pressure, SBP/DBP=systolic/diastolic blood pressure, MAP=mean arterial blood pressure
FiO2=fraction of inspired oxygen, Peep=positive end expiratory pressure, MV=mechanical ventilation
APMHR=age predicted maximum heart rate, RASS=Richmond Agitation Sedation Scale, DOE=dyspnea on exertion
Table 4. Outcomes of ICU Mobilization

Study
Study Design
(N= subjects)
Levels of
Evidence
(Sackett)
Physical Therapy
Interventions
Functional Outcomes
Martin UJ. 200530
Retrospective
Treatment group
underwent UE/ LE
ther ex., trunk control
tasks; cycle ergometry,
inspiratory muscle
training and functional
training x 5 days/ week
Increased UE/ LE
strength as measured
on 5 point scale;
increased inspiratory
muscle force
(maximal NIF)
N/A
Treatment group
underwent UE/ LE ther
ex., breathing retraining
ex., and functional
training x 5 days/ week x
6 weeks
Increased UE/ LE
strength (hand-held
dynamometry) and
respiratory muscle
force (PImax & PEmax)
N/A
Strength/ ROM
One-group pretestposttest design

N = 49 enrolled;
49 completed
study)
Chiang LL. 200622
Prospective
2B
RCT
(N = 39 enrolled;
32 completed
study)
(15 control; 17
treatment group)
QOL
Other notable findings
Mobility
All patients bedridden
initially; Following
rehab program,
patients demonstrated
higher scores on
FIM for supine <> sit
and sit<> stand but
no differences for
ambulation/ stairs
Treatment group
had higher scores
on FIM and Barthel
Index following 3
and 6 weeks of PT
intervention

Bailey P. 2007 23
Prospective
Twice daily PT/ activity

session
N/A
N/A
Median distance
ambulated by
survivors was 64.6
meters
(N=103 patients)

Morris PE. 200825
Prospective
2B
Cohort study
(N=330; 165
intervention; 165
usual care)
implemented 7 days/
consisting of PT, critical
care RN and nursing
assistant
N/A
N/A
Intervention group
reached mobilization
milestones sooner (eg:
day to first OOB)

Thomsen GE.
200824
Prospective
Functional mobility
training (ROM; sitting at
edge of bed and OOB;
ambulation)
N/A
N/A
[N = 104 patients
(91 Survivors)]
Schweickert WD.
200920
Prospective
1B
RCT
(N=104; all
patients completed
study)
Treatment group
underwent progressive
UE/ LE ther ex., trunk
control/ balance activities
and functional training
including ADLs x 7
days/ week
No difference in
UE/LE strength as
measured by MRC or
hand grip
N/A
More advanced
mobilization activities
(OOB transfers &
sitting; ambulation)
increased within 24
hours of transfer
to the unit where
mobilization is
emphasized
Increased % of
intervention group
returned to functional
baseline as defined
by FIM and Barthel
Index and had greater
unassisted walking
distance at hospital
d.c.
Burtin C. 200921
Prospective
RCT
(N = 90 enrolled;
67 completed)
(36 control; 31
treatment group)
2B
Both groups received UE/

LE ther ex and functional
training x 5 days/ week
treatment group had
additional cycling session
x 20 minutes total
duration x 5 days/ week
Hand held
dynamometry:
no difference in
quadriceps muscle
force at ICU d.c. but
increased quadriceps
muscle force noted
at hospital d.c.;
Improved
QOL (SF-36
PF) at time of
hospital d.c.
No differences at time
of discharge from ICU.
Treatment group had

increased 6 MWT
distance and at time of
hospital discharge
No difference in
hand grip strength at
either time point
setting is a post intensive care unit (vent

rehab unit; MV > 14 days)
negative correlation between UE
strength at admission and weaning
duration
no control group
setting is a post-ICU

median MV days 46

may not be applicable to acute
care/ ICU
increased vent free time in treatment
group
moderate correlation b/w limb strength
and ADL performance and mobility
impaired cognitive status at a baseline
improved throughout intervention
period
small sample size
Study provides criteria (neurologic/
circulatory/ respiratory) for initiating
mobility
Study verifies that early mobilization of
ICU patients can be achieved
Increased number of co morbid
conditions did not influence
ambulatory status
Ambulation distance at ICU discharge
may predict post-acute d.c. destination
No control group for comparison
Protocol for mobilization is well
defined
Intervention group had shorter hospital
& ICU lengths of stay potentially
leading to cost savings
Intervention group had increased PT
frequency throughout hospital length of
stay
On average, protocol patients initiated
OOB 7 days earlier compared to usual
care
No differences in MV duration or d.c.
destinations
Nonrandomized
Mean distance of ambulation at d.c.
was 200 feet
Sedatives, even intermittent sedation
administration decreased likelihood of
ambulation
female gender and reduced illness
severity (ie, APACHE score) associated
with greater ambulation
Early mobilization associated with
reduced incidence of delirium and
ventilator free days
MV did not preclude acquisition of
mobility milestones
Study included performance of ADLs
87% of therapy sessions completed
No differences in ICU or hospital
length of stay
No differencein ICU-acquired
weakness
moderate correlation between
quadriceps strength and 6 MWT and
SF-36
trends noted for proportion of patients
who were ambulatory and/ or
discharged home (study not adequately
powered)
no differences in ability to transfer from
sit<> stand or ambulate independently
between groups
no differences in weaning time, length
of ICU or hospital stay
Needham DM
201026
Prospective QI
project
3B
Functional mobility
training (supine to
sit; sitting at edge of
bed; OOB transfers;
ambulation)
N/A
N/A
Greater percentage
of patients engaged
in more advanced
mobilization (i.e.:
OOB activities)
Additional QOL goals accomplished:

increase number of PT/ OT consults &
interventions; reduction in missed PT/
OT sessions

reduced use of sedative drugs

increased alertness with reduced
delirium

reduced ICU and hospital LOS
2B
implemented 7 days/
consisting of PT, critical
care RN and nursing
assistant
N/A
N/A
Patient participation in
an ICU mobilization
program was
associated with
reduced hospital
readmission or death
in the year following
hospitalization
WP patients performed
UE/ LE ther. ex including
UE/ LE cycling and
mobilization 6 days/week
N/A
Both groups
demonstrated
improvement in FIM
scores
Case controlled
(N = 57 total (27
pre QI; N=30
post QI)
Morris PE 201118
Retrospective
cohort analysis
of survivors from
prior study*** (see
Morris 2008)
N = 258 of 280
survivors of acute
respiratory failure
Montagnani G
201131
Retrospective
Non-equivalent
Pretest-Posttest
Control Group
Design
(N= 56 weaning
program (WP);
N= 63 pulmonary
rehab (PR))
Dyspnea
scores
declined in
both groups
PR subjects exercise
on treadmill/ UE/ LE
ergometer and low
intensity PREs daily x
15- 21 days
Study determined additional variables

associated with hospital readmission
including female gender, co-morbidties,
and tracheostomy
>50% of survivors will have a
readmission or die in the year following
hospitalization
Setting was post-acute/ long-term

weaning center
Included objective measurement of
dyspnea
FIM may be useful outcome tool in this
novel setting for patients who require
prolonged MV

Patients who are deemed
difficult to wean
Not randomized with small sample size
PT=physical therapy, OT=occupational therapy, MV=mechanical ventilation, NIF=negative inspiratory force, QOL=quality of life, N/A=not applicable
FIM=functional independence measure, PImax=peak inspiratory pressure, PEmax=peak expiratory pressure, HR= heart rate, ICU=intensive care unit
D.C.=discharge, c/o=complains of, s/p=status post, OOB=out of bed, RN=nurse, RCT=randomized controlled trial, LOS=length of stay
APACHE=acute physiology and health evaluation score, 6MWT=six minute walk test, MRC=Medical research council SF-36=short form health survey
Table 5. Medical Research Council (MRC) Scoring System for Muscle Strength*
Score
Description
No visible contraction
Visible muscle contraction, but no limb movement
Movements Assessed
Upper Extremity:
Lower Extremity:
Active movement, but not against gravity
Shoulder abduction
Hip flexion
Active movement against gravity
Elbow flexion
Knee Extension
Active movement against gravity and resistance
Wrist extension
Dorsiflexion
Active movement against full resistance
Maximum score: 60 (4 limbs; 3 movements per extremity with maximum score of 15 points per limb)
Minimum score: 0 (quadriplegia)
*Adapted from Schweickert and Hall. ICU-Acquired Weakness. Chest. 2007;31:1541-1549.
tion lasting less than 3 minutes. In studies that reported

on adverse events, accidental removal of patient support
equipment happened rarely (<1%) further highlighting the
safety of patient mobilization. Burtin et al21 reported one
Achilles tendon rupture in their intervention group that
used in-bed cycle ergometry. There were no serious adverse
events that required life saving measures or alterations in
the patients medical care.
Functional Outcomes
Muscle Strength
Extremity muscle strength was measured by hand-held
dynamometry or manual muscle testing [eg, Medical Research Council (MRC) scoring] in 4 studies as noted in
Table 4 and defined in Table 5. Medical Research Council
scores, handgrip, and extremity strength did not differ at
time of discharge from the ICU20,21 but Burtin et al21 showed
increased quadriceps muscle force at time of hospital dis-
10
charge. In postacute settings where patients were mechanically ventilated for a minimum of 14 days prior to transfer,
strength gains were observed. In one study,30 subjects were
mechanically ventilated for a median duration of 46 to 52
days (22.8 80.8 days) and demonstrated upper extremity/
lower extremity (UE/ LE) strength gains measured by dynamometry. In another study30 patients were mechanically
ventilated for 18.1 7 days and also demonstrated UE/LE
strength gains by manual muscle testing (MMT). Both studies found increases in respiratory muscle strength.
Functional Mobility: The most frequently described functional outcomes assessed were: time to mobility milestones
[eg, time to first out of bed (OOB), standing]; ambulation
distance,24 the Barthel Index,33 the Functional Independence Measure (FIM)34 or select parts of the FIM [Functional Status Score in the ICU (FSS-ICU)].4 The FSS-ICU, similar
to the FIM, rates functional activities between 1 (total assist)
and 7 (complete independence). A score of 0 is assigned

if a patient is unable to perform a task. Only 5 of the items
from the FIM are included: (1) rolling, (2) transfer from supine to sit, (3) sitting at the edge of bed, (4) transfer from sit
to stand, and (5) ambulation are combined in the cumulative FSS-ICU score.4
Mobility milestones were accomplished earlier in the
intervention groups than the comparison groups in 4 studies.20,24-26 Compared to controls, ambulation frequency was
greater in the study by Thomsen et al24 and ambulation distance was greater at time of hospital discharge in the studies by Schweickert et al20 and Burtin et al.21
Objective measures such as the FIM & Barthel Index
improved in the intervention groups at time of hospital
discharge but without significant differences at time of
ICU discharge in the study by Schweickert et al.20 In the
postacute care setting, bed mobility and transfers were improved in 3 studies22,30,31 but ambulation/locomotion were
only improved in the studies by Chiang et al22 and Montagnani et al.31
Quality of Life & Patient Symptoms: Burtin et al21 noted
improvements in the physical functioning (PF) subscore
of the SF-36 at time of hospital discharge but quality of
life (QOL) was not reported for the transition from ICU to
ward. Dyspnea was measured in the postacute care setting in the study by Montagnani et al.31 These patients were
hospitalized for approximately 40 days prior to postacute
admission, had tracheostomies, and required prolonged
mechanical ventilation. The symptom of dyspnea was reduced following the rehabilitation period.
DISCUSSION
The focus of critical care medicine in the ICU is restoration of physiological or hemodynamic stability and
prevention of death. The historical approach to achieve
these goals has included long periods of immobility and
bedrest. The impact of life-sustaining ICU technology on
patients that have required sedation, long-term mechanical ventilation, and bedrest has been profound with respect to severe muscle weakness, functional impairments,
and loss of quality of life.15 By understanding the negative sequella of ICU-induced bed rest, investigators are
attempting to correct these derangements by reducing the
dosage and frequency of sedative medication and mobilizing critically ill patients once hemodynamic stability
has been achieved. We have reviewed published reports
that have studied this clinical approach.
Safety: Studies included in this review persuasively conclude that the mobilization of critically ill but stable patients in the ICU and immediate postacute environment,
who have required a period of mechanical ventilation, can
be done safely with minimal risk to the patient. Although
most studies included patients receiving 4 or more days of
mechanical ventilation, Pohlman et al20 demonstrated the
safety of physical therapy intervention occurring within
two days of intubation. The most common untoward event
was transient oxygen desaturation that was attenuated by

rest and increasing the FiO2 delivered to the patient. Line
dislodgment and/or accidental extubation, frequently mentioned dangers of mobilization, happened rarely, further
highlighting the safety profile of patient mobilization.
In all studies, hemodynamic, respiratory, and cognitive
criteria were established a priori to ensure patient safety
(Table 3). These criteria guided the clinicians to determine
patient eligibility for mobilization and, it is presumed, limited untoward events by providing the treating physical
therapist and/or occupational therapist parameters to guide
the intensity of the mobilization sessions. Mobilization was
loosely described in most studies citing therapist discretion
for advancing activities based on patient tolerance and stability. However, Stiller et al27 provided an algorithm for
initiating and terminating therapy sessions based on physiologic and laboratory data while Morris et al25 provided an
algorithm for mobility progression based on patients physical capabilities.
Overall activity-induced increases in HR, BP, respiratory
rate (RR), tidal volume, and minute ventilation were within
acceptable ranges, challenging the perception that patients
in the ICU are too sick to participate in mobilization activities.4,27,28 As noted multiple studies have reported on safety
and feasibility but the lack of reported negative events could
reflect a bias of nonreporting of adverse incidents.
Muscle Strength: Although it is generally accepted that patients in critical care settings for prolonged periods of time
are often bed ridden, deconditioned, and weak, muscle
strength was infrequently reported as an outcome measure
in the reviewed studies. In studies that did address muscle
force production, strength was not significantly improved
in the ICU20,21 but did improve by the time of discharge
from the hospital.21 Interestingly, strength was consistently
improved in the postacute care setting.22,30
Functional Mobility: The literature reviewed supports
improvements in functional mobility following early and
progressive physical therapy/occupational therapy (PT/ OT)
in the ICU but the measurement of this outcome was not
uniform across the literature. For example, as mentioned
in the results section, variability of outcome measurements
included acquisition of mobility milestones,18,20,21,23,24,26
FIM,20,22,30,31 FSS-ICU,4 and the Barthel Index.33 Time to
mobility milestones was reduced and patient participation
in advanced mobilization activities occurred more frequently in ICUs where mobilization and PT/ OT were emphasized.20,24-26 Within the ICU setting, objective measures
such as the FIM & Barthel Index were used infrequently
although two of the cited studies used these tools.4,20
The FIM and Barthel Index scores improved in the intervention group in the study by Schweickert et al20 with over
59% of patients achieving functional independence (FIM
5) compared to 35% of the control group at time of hospital discharge. The FIM scores also improved following
rehabilitation in the postacute setting.22,30,31 Use of the FIM,
or the related FSS-ICU4 to measure patient disability and to
11
compare functional outcomes is attractive since the tool is

well known to rehabilitation professionals. However, the
validity and reliability of this tool has not been established
in the ICU setting.
Quality of Life & Patient Symptoms: Quality of life and
patient symptoms were seldom measured within the ICU.
One study21 measured QOL and one study measured patients symptoms.31 Burtin et al21 demonstrated improvements in the physical functioning domain of the SF-36 at
hospital discharge while Montagnani et al31 reported reduced patient dyspnea. As noted in the introduction, quality of life and neuropsychological impairments such as
depression, anxiety, and posttraumatic stress disorder are
negatively impacted by prolonged mechanical ventilation
and ICU duration. Rehabilitation in the ICU and its influence on these factors should be an area of future research.
The physiology and complications of bed rest are
well understood. Intensive care unit-acquired weakness
and functional dependency are recognized as unfortunate consequences of prolonged duration in ICUs and
mechanical ventilation. Although sedative medications
are used to reduce metabolic energy demand for patients
in respiratory failure they inhibit participation in exercise
and functional activity and often cause disturbances in
levels of arousal. Despite the inherently complex environment and challenges that face critical care teams, including the human resources required to safely mobilize
patients, feasibility and safety has been demonstrated as
noted in Table 2. Critically ill patients can exercise, sit
up, transfer to bedside chairs, and ambulate in the hallways; however, few published papers have randomized
and controlled this intervention. The work of Schweickert
et al,20 Burtin et al,21 and Chiang et al22 have found that
participation in monitored programs of physical activity
can lead to statistically significant improvements in ambulation independence, reduced duration of mechanical
ventilation, better ability to perform self care activities,
and improved respiratory function.
CONCLUSION/IMPLICATIONS FOR FUTURE RESEARCH
In summary, the body of evidence that has studied the
mobilization of critically ill patients is small. The few randomized controlled trials include a total of only 171 patients limiting the strength of evidence. Based on the studies reviewed, early physical therapy and ICU mobilization
is feasible and safe. Acquisition of mobility milestones is
enhanced in ICUs that promote early rehabilitation. Improvements in quality of life and muscle strength cannot be
determined at this time.
In reviewing the literature, there are several questions
that must be addressed. These questions include, but are
not limited to: (1) How do published papers reflect current
practice as mobilization has been reported in a small percentage of ICUs? (2) What is the appropriate level of clinical
expertise or experience required to safely work in a critical
care environment? (3) What intensity, frequency, and dose
12
of physical activity will lead to optimal patient outcomes?

(4) What generalization to other patient populations can
be made since the majority of patients studied are found
in medical ICUs? (5) Should all patients who require mechanical ventilation or ICU admission be referred to physical therapy? And (6) Are there optimal patient populations
who would benefit most from early mobilization, as well
as populations for whom physical therapy is clearly contraindicated? The answer to these questions will provide an
evidence-based approach to optimize patient outcomes for
the critically ill patient.
REFERENCES
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barriers and benefits. Crit Care Clin. 2007;23:1-20.
2. Truong AD, Fan E, Brower RG, Needham DM.
Mobilizing patients in the intensive care unitfrom pathophysiology to clinical trials. Crit Care.
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3. Kress JP, Clinical trials of early mobilization of critically
ill patients. Crit Care Med. 2009;37[Suppl.]:s442-s447.
4. 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):254262.
5. 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; quiz 566-568.
6. Norrenberg M, Vincent JL. A profile of European intensive care unit physiotherapists. Intensive Care Med.
2000;26:988-994.
7. Nava S, Ambrosino N. Rehabilitation in the ICU: the European phoenix. Intensive Care Med. 2000;26:841-844.
8. Dejonghe B, Sharshar T, Lefaucheur JP, et al. Paresis acquired in the intensive care unit: A prospective multicenter study. JAMA. 2002;288:2859-2867.
9. Stevens RD, Dowdy DW, Michaels RK, et al. Neuromuscular dysfunction acquired in critical illness: a systematic review. Intensive Care Med. 2007;33(11):1876-1891.
10. Herridge MS, Cheung AM, Tansey CM, et al. One year
outcomes in survivors of the acute respiratory distress
syndrome. N Engl J Med. 2003;348:683-693.
11. Cheung AM, Tansey CM, Tomlinson G, et al. Two-year
outcomes, health care use and costs in survivors of
ARDS. Am J Resp J Crit Care Med. 2006;174:538-544.
12. Herridge MS, Tansey CM, Matte A, et al. Functional
disability 5 years after acute respiratory distress syndrome. N Engl J Med. 2011;364:1293-1304.
13. Harper CM, Lyles YM. The physiology and complications
of bedrest. J Am Geriatr Soc. 1988;36(11):1047-1054.
14. Bergouignan A, Rudwill F, Simon C, Blanc S. Physical
inactivity as the culprit of metabolic inflexibility:
evidences from bedrest studies. J Appl Physiol. 2011
Aug 11 (Epub ahead of print).
15. Bloomfield SA. Changes in musculoskeletal structure
and function with prolonged bedrest. Med Sci Sports
Exerc. 1997;29(2):197-206.
16. Brower RG, Consequences of bed rest. Crit Care Med.

2009;37(10):422-428.
17. Hopkins RO, Spuhler VJ, Thomsen GE. Transforming
ICU culture to facilitate early mobility. Crit Care Clin.
2007;23:81-96.
18. Morris PE, Griffen L, Berry M, et al. Receiving early
mobility during and intensive care unit admission is a
predictor of improved outcomes in acute respiratory
failure Am J Med Sci. 2011;341(5):373-377.
19. Centre for Evidence-based Medicine. Levels of
Evidence (March 2009) Website. Available at www.
cebm.net. Accessed September 26, 2011.
20. Schweickert WD, Pohlman MC, Pohlman AS. Early
physical and occupational therapy in mechanically
ventilated, critically ill patients: a randomized
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in critically patients enhances short-term functional
recovery. Crit Care Med. 2009;37(9):2499-2505.
22. Chiang LL, Wang LY, Wu CP, Wu HD, Wu YT. Effects
of physical training on functional status in patients
with prolonged mechanical ventilation. Phys Ther.
2006;86:1271-1281.
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is feasible and safe in respiratory failure patients. Crit
Care Med. 2007;35(1):139-145.
24. 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):11191124.
25. 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):22382243.
26. 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;91:536-542.
27. Stiller K, Phillips, AC, Lambert P. The safety of mobilisation and its effects on haemodynamic and respiratory
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responses to the early mobilization of the intubated,
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D, Pantani L, Ambrosino N. Use of the functional
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13
Respiratory and Hemodynamic Responses to

Mobilization of Critically Ill Obese Patients
Arzu Genc, Assoc. Prof, PT;1 Seher Ozyurek, MSc, PT;1
Ugur Koca, Assoc. Prof, MD; 2 Ali Gunerli, Prof, MD 2
School of Physical Therapy and Rehabilitation, Dokuz Eylul University, Izmir, Turkey
Faculty of Medicine, Department of Anesthesiology, Dokuz Eylul University, Izmir, Turkey
1
ABSTRACT
Purpose: The aim of this study was to investigate the effects of
mobilization on respiratory and hemodynamic parameters in
critically ill obese patients. Methods: Critically ill obese patients (n=31) were included in this retrospective study. Data
were collected from patients files and physiotherapy records
of mobilization sessions. Heart rate (HR), systolic/diastolic/
mean blood pressure, respiratory rate (RR), and percutaneous
oxygen saturation (SpO2) were recorded. Cardiorespiratory
parameters were collected just prior to the mobilization, just
after the completion of the mobilization and after 5 minutes
recovery period. Respiratory reserve was calculated before
and after the mobilization. Results: A total of 37 mobilization sessions in 31 obese patients (mean age: 63.3 years,
mean BMI: 32.2 kg/m2) who received physiotherapy were
analyzed. Respiratory rate increased significantly after the
completion of the mobilization compared to initial values (p
< 0.05). SpO2 significantly increased (p < 0.05) and all other
parameters remained similar (p > 0.05) compared to initial
values after the recovery period. Mobilization resulted in a
significant increase in respiratory reserve (p < 0.05). Conclusion: Early mobilization in intensive care unit promotes respiratory reserve in obese patients. We found that mobilization
can be performed safely in critically ill obese patients if cardiorespiratory parameters are continuously monitored.
Key Words: obesity, mobilization, critically ill patients,
physiotherapy
INTRODUCTION AND PURPOSE
Obesity is among the most serious public health problems1,2 that affects many people and often requires multidisciplinary treatment.3 There is overwhelming evidence that
the prevalence of obesity, defined as having a body mass
index (BMI) of 30 kg/m2,4 is increasing worldwide.2,5
Obesity is associated with increased risk of chronic diseases, secondary medical complications, and reduced health
related quality of life.6 Approximately one-third of patients
admitted to intensive care units (ICU) are obese and nearly
Address correspondence to: Seher Ozyurek, MSc, PT,
School of Physical Therapy and Rehabilitation, Dokuz
Eylul University, Izmir, Turkey, Ph: +90 232 412 49 29,
Fax: +90 232 277 50 30 (seher.ozyurek@deu.edu.tr).
14
7% are morbidly obese.7,8 The term morbid obesity refers to

adults with BMI greater than or equal to 40 kg/m2.2
Several studies have investigated the effect of obesity
on outcome in ICU setting.9-14 Many of these studies have
shown increased morbidity and mortality.12-14 Data on outcomes of critically ill patients indicated that obese patients
were more likely to have complications including acute
respiratory distress syndrome (ARDS),10,12 septic shock,14
acute renal failure,10,12 and acquired infection.12,14 Besides
these severe events, obesity is associated with increased
risk of ARDS11 and increased length of ICU stay.11-14
As patients survive chronic illness, immobilization
complications such as muscle weakness and atrophy, contractures, decreased cardiac reserve, venous thromboembolism, and orthostatic hypotension are more apparent.15
For these reasons, physiotherapy interventions should be
initiated as early as possible after the acutely ill patient is
admitted to the ICU.16 Many studies showed that mobilization of critically ill patients in the earliest days of critical
care can result in improved patient outcomes.17-20
Recently, there has been an interest in early mobilization of ICU patients. Although many authors agree that mobilization of acutely ill patients is feasible and safe;20-22 to
our knowledge, there are no studies that were specifically
implemented in critically ill obese patients.
The aim of this retrospective study was to investigate
the effects of mobilization on respiratory and hemodynamic parameters in critically ill obese patients. We focused
on whether patients responses to mobilization were within
the normal ranges.
METHODS
Design
The study was retrospective. Data were collected from
patients files and physiotherapy evaluation forms.
Patient and settings
Critically ill obese patients who received mobilization
sessions in their physiotherapy program during the ICU stay
in the 18-bed Anesthesiology and Reanimation Intensive
Care Unit of the university hospital between January 2007
and January 2010 were included in the study. This study
was approved by the Institutional Review Board at Dokuz
Eylul University.
Patients were classified as obese according to the definitions of the World Health Organization criteria4 based on
BMI formula: BMI= body weight (kg)/height2 (m2). Obese

patients were defined as having BMI of 30.00 kg/m2.
Inclusion criteria for receiving mobilization sessions
consisted of stable conscious state and able to understand
and follow commands appropriately, hemodynamically
stable (not requiring inotropes), body temperature < 38C,
hemoglobin levels stable and > 7 g/dL, percutaneous oxygen saturation (SpO2) > 90%, mean blood pressure (MBP)
> 60 mmHg, no orthopedic and neurological contraindications.23
Mobilization protocol
The standard mobilization protocol is that mobilization
is begun as soon as patients cardiorespiratory system is stable (as defined above). Per hospital standard protocol, mobilization was begun as soon as the patients cardiorespiratory system was stable (as defined above). Hemodynamic
and respiratory parameters were continuously recorded at
all stages of mobilization sessions. The mobilization progression was based on the patients general clinical status,
ability, and willingness.
Physiological responses were monitored continuously
as the patient progressed through the mobilization protocol
in order to prevent adverse effects of mobilization.
The following criteria were chosen as intolerance findings:
20 mmHg increase or decrease in systolic blood
pressure (SBP)/diastolic blood pressure (DPB),
20 beats/minute increase or decrease in heart rate
(HR),
SpO2 < 90%, and
paradoxical breathing, dizziness, perspiration, and
faintness.18
Intolerance findings were recorded by the physical therapists to evaluate the safety of patients and patients abnormal responses to mobilization.
Data collection and outcome measure
One physiotherapist specialized in intensive care collected the information retrospectively from the obese patients files (see Table 1). Data were collected in 3 categories:
patients demographics (age, gender, height, body weight,
BMI), patients medical information, and physiotherapy records of mobilization sessions during their ICU stay.
Hemoglobin levels, platelet counts, white cell counts,
and blood glucose levels were collected from the most recent blood analyses and body temperature was recorded
from the monitor (Draeger Medical Systems Inc, U.S.A) before mobilization.
The following hemodynamic and respiratory parameters were taken from the monitor: HR, SBP, DBP, MBP, respiratory rate (RR), and SpO2. Measurements were collected in 3 stages: (1) just prior to the mobilization in supine
position (premobilization), (2) just after the completion of
the mobilization when the patient had been returned to the
supine position (postmobilization), and (3) after 5 minutes
recovery period (5 minutes recovery).
The ratio of partial pressure of oxygen in arterial blood
to the inspired fraction of oxygen (PaO2/FiO2) was calcu-
lated from the most recent arterial blood gas samples for
assessing the respiratory reserve before and after the mobilization. Respiratory reserve reflects oxygenation.23
Data analysis
The statistical package SPSS 15.0.0 for Windows (SPSS
Inc., Chicago, IL, USA) was used for statistical analysis.
Level of significance was set at p < 0.05. All continuous
variables were evaluated for normality using KolmogorovSmirnov test with Lilliefors Significance Correction. Continuous variables were expressed as mean standard deviation (if data were normally distributed) or as medians
in combination with quartiles and percentiles (if data were
not normally distributed). Mobilization data were analyzed
with a one way repeated measure analysis of variance
(ANOVA). Statistically significant changes were further analyzed with post-hoc Bonferroni t-test. To compare changes
in respiratory reserve between before and after mobilization, paired sample t-test was performed.24
RESULTS
Retrospective analysis of 31 patients files who received
mobilization in their physiotherapy program during the
ICU stay fulfilled all aspects of the study. A total of 31 obese
patients received 37 mobilization sessions in ICU. Baseline
characteristics of the patients are summarized in Table 1.
All mobilization sessions were performed after patients
were extubated. Mobilization events included 26 (70.3%)
sitting on the edge of the bed, 3 (8.1%) standing, 8 (21.6%)
walking to the chair and sitting in the chair.
A total of 7 intolerance findings were recorded in 6
patients. One patient had 2 intolerance findings. Intolerance findings included 4 increase or decrease in SBP (20
mmHg or more), 3 increase or decrease in HR (20 beats/
minute or more). Despite the intolerance findings, no deterioration in clinical status occurred during the mobilization sessions.
Effects of mobilization on hemodynamic parameters
The results showed that HR was significantly different
when 3 mobilization stages were compared (F= 3.79, p=
0.049). Heart rate significantly decreased in the 5 minute
recovery period when compared with postmobilization
values (p < 0.05). There were no significant differences in
other hemodynamic parameters (p > 0.05) (Table 2).
Effects of mobilization on respiratory parameters
Significant changes were seen in RR (F = 17.35, p = 0.00)
with progression of mobilization. Respiratory rate significantly increased from premobilization to postmobilization. A significant RR reduction was seen in the 5 minute recovery period when compared with postmobilization values (p < 0.05).
Mobilization caused a significant change in SpO2 (F=
4.11, p= 0.02). After a 5 minute recovery period, SpO2 significantly increased compared with premobilization values
(p < 0.05) (Table 2). Mobilization resulted in a significant
increase in respiratory reserve when compared with premobilization values (t = -5.440 p = 0.00) (Table 2).
15
Table 1. Baseline Characteristics of the Patients

Age (years)
Mean SD
63.3512.25
Range
38.00-83.00
Gender [n(%)]
Male
15 (48.4%)
Female
16 (51.6%)
Body weight (kg)

Mean SD
87.4811.78
Range
70.00-120.00
Height (cm)
Mean SD
164.549.79
Range
145.00-184.00
BMI (kg/m2)
Mean SD
32.242.53
Range
30.04-39.56
Diagnosis at ICU admission [n(%)]

Medical
3 (9.7%)
Surgery
28 (90.3%)
Body temperature (0C)

Mean SD
36.970.38
Range
36.00-37.70
Hemoglobin levels (g/dL)

Mean SD
10.691.75
Range
7.10-13.70
Platelet counts (cells/mm )

3
Mean SD
Range
214.229128.587
51.000-621.000
White cell counts (cells/mm3)

Mean SD
12.0703.009
Range
5.600-18.300
Blood glucose levels (mg/dL)

Mean SD
Range
161.2148.65
101.00-286.000
DISCUSSION
In this retrospective study, we investigated the hemodynamic and respiratory responses to early mobilization and
effects of the mobilization on oxygenation in critically ill
obese patients. Although mobilization resulted in significant increases in RR after mobilization, all parameters were
similar in the 5 minute recovery period when compared
with initial values, except for SpO2. Increases in RR may be
due to the patients efforts to compensate for the increased
physical activity. It was an expected response to increased
work of breathing. Nonsignificant HR, SBP, DBP, and MBP
increases were seen during postmobilization period. This
result showed that mobilization did not put excess hemodynamic stress on obese patients. Significant increase was
observed in SpO2 in the recovery period when the patient
was taken back to supine position in bed. Additionally, we
found that respiratory reserve significantly improved after
mobilization. Although the 7 of 37 mobilization sessions
had intolerance findings, mobilization did not result in deterioration in clinical status. On the two of 7 intolerence
findings, the magnitude of SBP or HR increases were very
small when compared to chosen intolerance findings (in
one patient: 21 beats/minute increase in HR, in the other
patient: 21 mmHg increase in SBP). No specific intervention was applied during mobilization to stabilize cardiorespiratory parameters. Patients hemodynamic and respiratory responses to mobilization were within the normal value.
The main finding of the present study is that mobilization can be performed safely in critically ill obese patients if
cardiorespiratory parameters are continuously monitored.
This finding is similar to other mobilization studies,18,20-22
which investigated the effects of mobilization in critically
ill patients with other diagnosis.
There are several outcome studies investigating the effect of obesity in ICU.9-11 It is well known that obesity is
related to increased morbidity and mortality.12-14 In the literature, it is shown that early mobilization improves functional outcomes in critically ill patients.17-20 Although mo-
Table 2. The Comparison of Hemodynamic and Respiratory Parameters between Premobilization, Postmobilization,
and Recovery Period (mean standard deviation)
Premobilization
Postmobilization
Recovery
HR (beat/minute)
91.56 17.50
94.4515.97
90.4014.91
0.049
SBP (mmHg)
130.9415.89
134.0817.85
130.7216.68
0.194
DBP (mmHg)
70.0012.30
72.5612.80
69.5611.63
0.081
MBP (mmHg)
91.4814.92
94.3714.75
90.5613.88
0.119
RR (breath/minute)
23.324.97
25.895.51
23.294.71
0.000
SpO2* (%)
98.0
(95.5-100.0)
99.0
(96.0-100.0)
99.0
(96.5-100.0)
0.020
PaO2/FiO2
230.1585.80
276.8299.46
0.000a
HR: heart rate, SBP: systolic blood pressure, DBP: diastolic blood pressure, MBP: mean blood pressure, RR: respiratory rate, SpO2= percutaneous oxygen saturation, %=percent, PaO2/FiO2: the ratio of partial
pressure of oxygen in arterial blood to the fraction of inspired oxygen
: statistically different from post-mobilization values( p < 0.05).
: statistically different from pre-mobilization values( p < 0.05).
p: ANOVA, boldface p values were statistically significant.
a
: paired sample t- test
*: expressed as medians in combination with quartiles and percentiles
16
bilization is a common practice in most ICUs, there is a

lack of data available on obese population. There is only
one case report of a morbidly obese patient (BMI: 69 kg/m2)
with multiorgan failure successfully mobilized throughout
her ICU stay.25 However that report did not investigate the
hemodynamic and respiratory responses to mobilization.
To the best of our knowledge, no previous studies have investigated the effects of mobilization on hemodynamic and
respiratory parameters in critically ill obese patients. This
study is the first research related to early mobilization in
obese patients in ICU. Our current findings showed significant increases in RR after mobilization that returned
premobilization values in the recovery period indicating
the safety of mobilization as a consequence of normal responses to physical demand. Increases in SpO2 and PaO2/
FiO2 reflect the improvement of oxygenation and this result
showed that mobilization may improve patient outcomes.
Our obese patients were able to participate in early mobilization and the patients demonstrated clinical stability
through the ICU stay. Clinical and physiologic stability of a
patient has been described as the whole state of neurological and cardiorespiratory stability.27 Stiller et al23 has outlined
the safety issues that should be considered when mobilizing
critically ill patients. We selected the inclusion criteria according to these safety issues. The mobilization progression
was based on the patients general clinical status, and ability.
None of the patients had an adverse event in mobilization.
The majority of the patients (n=28, 90.3%) in the current study had surgery. Although our patients did not have
pulmonary complications, it is well documented in the
literature that obese patients have been reported to have
a higher incidence of postsurgical pulmonary complications.26 Efficacy and safety of early postoperative mobilization in critically ill patients has been shown in prior
studies.18,20,27,28 All the patients in Sendurans18 and Zafiropoulos20 studies and 38.7% of the patients in Stillers21
study were postoperative. All of these authors applied
early mobilization in ICU and found that mobilization is
feasible and safe in patients postsurgery. Our findings support these literature findings.
Zafiropoulos et al20 investigated the effects of mobilization on respiratory and hemodynamic variables in intubated, ventilated abdominal surgical patients and found that
mobilization was associated with significant increases in
RR. Similar to Zafiropoulos et als20 finding an increase in
RR was found in our study after mobilization. We did not
include the intubated and mechanically ventilated patients
in our study. However, in Stillers21 study, 7 patients (22.6%)
were intubated, ventilated and they found the same result
as well. In contrast with results of Zafiropoulos,20 Stillers,21 and Sendurans18 studies, we did not find a significant
increase in HR after mobilization.
We found that the respiratory reserve of the patients
significantly increased after mobilization and SpO2 significantly increased after 5 minutes recovery. It was expected
that the mobilization would enhance the oxygen transport
of these patients, due to positive effects of erect position on
alveolar ventilation and ventilation/perfusion matching.29
Researchers have speculated that duration of sitting and

walking distance may affect the cardiopulmonary responses to a recovery period.18 In our study, we did not measure
the duration of sitting and walking distance to the chair.
This is a limitation of our study.
In our study, only 8 patients (21.6%) managed to walk
to the chair and sit in the chair. The majority of our patients (n=26, 70.3%) were seated on the edge of the bed.
We think that participation of a large number of subjects in
higher level of mobilization stages may affect the results.
This may be a limitation of our study.
CONCLUSION
We conclude that early mobilization is feasible and safe
in critically ill obese patients. Additionally, our study shows
the benefits of early mobilization on oxygenation improvement. Further randomized-control studies with larger number of patients are needed to contribute new knowledge
to physiotherapy literature for the obese population in the
ICU setting.
ACKNOWLEDGEMENTS
Abstract of this work was presented as a poster presentation in 23rd Annual Congress of the ESICM in Barcelona
2010 and ESICM published the abstracts in Intensive Care
Medicine 2010 Supplement 2 which contains abstracts of
scientific papers presented at the 23rd Annual Congress of
the European Society of Intensive Care Medicine.
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WHO Consultation on Obesity. Geneva, Switzerland:
WHO, 1998.
3. Rippe JM, McInnis KJ, Melanson KJ. Physician involvement in the management of obesity as a primary medical condition. Obes Res. 2001;9 Suppl 4:302S-311S.
4. World Health Organisation: Physical Status: The use
and interpretation of anthropometry, Geneva, Switzerland: World Health Organization 1995. WHO Technical Report Series.
5. Bjrntorp P. Obesity. Lancet. 1997;350:423-426.
6. Lean MEJ, Han TS, Seidell JC. Impairment of health
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for the identification of obesity. Arch Intern Med.
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7. Akinnusi M, Pineda L, El Solh A. Effect of obesity on
intensive care morbidity and mortality: a metaanalysis.
Crit Care Med. 2008;36:151-158.
8. Oliveros H, Villamor E. Obesity mortality in critically
ill adults: a systematic review and meta-analysis. Obesity. 2008;16:515-521.
9. Frat JP, Gissot V, Ragot S, et al. Impact of obesity in
mechanically ventilated patients: a prospective study.
Intensive Care Med. 2008;34(11):1991-1998.
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10. Anzueto A, Frutos-Vivar F, Esteban A, et al. Influence of

body mass index on outcome of the mechanically ventilated patients. Thorax. 2011;66(1):66-73.
11. Gong MN, Bajwa EK, Thompson BT, et al. Body mass
index is associated with the development of acute respiratory distress syndrome. Thorax. 2010;65(1):44-50.
12. Yaegashi M, Jean R, Zuriqat M, et al. Outcome of morbid obesity in the intensive care unit. J Intensive Care
Med. 2005;20:147-154.
13. Goulenok C, Monchi M, Chiche JD, et al. Influence
of overweight on ICU mortality: a prospective study.
Chest. 2004;125:1441-1445.
14. Bercault N, Boulain T, Kuteifan K, et al. Obesity-related
excess mortality rate in an adult intensive care unit:
A risk-adjusted matched cohort study. Crit Care Med.
2004;32(4):998-1003.
15. Dittmer DK, Teasell R. Complications of immobilization
and bed rest. Part 1: Musculoskeletal and cardiovascular
complications. Can Fam Physician. 1993;39:1428-1437.
16. 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.
17. Scheidegger D, Bentz L, Piolino G, et al. Influence of
early mobilisation of pulmonary function in surgical
patients. Eur J Intensive Care Med. 1976;2(1):35-40.
18. Senduran M, Yurdalan SU, Karadibak D, et al. Haemodynamic effects of physiotherapy programme in intensive care unit after liver transplantation. Disabil Rehabil. 2010;32(17):1461-1466.
19. Morris PE, Griffin L, Berry M, et al. Receiving early
mobility during an intensive care unit admission is a
failure. Am J Med Sci. 2011;341(5):373-377.
20. 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.
21. Stiller K, Phillips AC, Lamber P. The safety of mobilisation and its effect on haemodynamic and respiratory status of intensive care patients. Physiother Theor
Pract. 2004; 20(3):175-185.
22. Bourdin G, Barbier J, Burle JF, 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.
23. Stiller K. Safety issues that should be considered
when mobilizing critically ill patients. Crit Care Clin.
2007;23:35-53.
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River, NJ: Prentice Hall; 2000.
25. Korupolu R, Zanni JM, Fan E, et al. Early mobilisation
of intensive care unit patient: the challenges of morbid obesity and multiorgan failure. BMJ Case Reports.
2010; doi:10.1136/bcr.09.2009.2257.
18
26. Pasulka PS, Bistrian BR, Benotti PN. The risks of surgery
in obese patients. Ann Intern Med. 1986;104:540-546.
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28. Orfanos P, Ellis E, Johnston C. Effects of deep breathing exercise and ambulation on pattern of ventilation in post-operative patients. Aust J Physiother.
1999;45(3):173-182.
29. Stiller K. Physiotherapy in intensive care*: Towards an
evidence-based practice. Chest. 2000;118:1801-1813.
Physiotherapy in Critical Care in Australia

Susan Berney, PhD;1 Kimberley Haines, B.HSc (Physiotherapy);1 Linda Denehy, PhD2
Physiotherapy Department Austin Health Melbourne, Australia
School of Physiotherapy, The University of Melbourne, Australia
1
2
ABSTRACT
A physiotherapist is part of the multidisciplinary team in most
intensive care units in Australia. Physiotherapists are primary
contact practitioners and use a comprehensive multisystem
assessment that includes the respiratory, cardiovascular, neurological, and musculoskeletal systems to formulate individualized treatment plans. The traditional focus of treatment
has been the respiratory management of both intubated and
spontaneously breathing patients. However, the emerging
evidence of the longstanding physical impairment suffered
by survivors of intensive care has resulted in physiotherapists
re-evaluating treatment priorities to include exercise rehabilitation as a part of standard clinical practice. The goals
of respiratory physiotherapy management are to promote secretion clearance, maintain or recruit lung volume, optimize
oxygenation, and prevent respiratory complications in both
the intubated and spontaneously breathing patient. In the intubated patient, physiotherapists commonly employ manual
and ventilator hyperinflation and positioning as treatment
techniques whilst in the spontaneously breathing patients
there is an emphasis on mobilization. Physiotherapists predominantly use functional activities for the rehabilitation of
the critically ill patient in intensive care. While variability
exists between states and centers, Australian physiotherapists actively treat critically ill patients targeting interventions
based upon research evidence and individualized assessment. A trend toward more emphasis on exercise rehabilitation over respiratory management is evident.
Key Words: physiotherapy, intensive care
INTRODUCTION
A physiotherapist is part of the multidisciplinary team
in most intensive care units in Australia.1,2 They are primary
contact practitioners and use a comprehensive multisystem
assessment that includes the respiratory, cardiovascular,
neurological, and musculoskeletal systems to formulate
individualized treatment plans.3 Physiotherapists provide
treatment for respiratory complications including the application of noninvasive ventilation and exercise and rehabilitation for the prevention and management of intensive
care acquired weakness (ICUAW) and deconditioning asAddress correspondence to: Susan Berney, PhD,
Physiotherapy Department, Level 3 Harold Stokes
Building, PO Box 5555, Heidelberg, Australia 3084
(sue.berney@austin.org.au).
sociated with immobility.4 Traditionally the management

of respiratory complications such as retained pulmonary
secretions, atelectasis, and the avoidance of reintubation
has been the major focus of physiotherapy treatment for the
critically ill patient. However, the emergence of evidence
reporting that many survivors of intensive care suffer long
standing weakness and functional limitation as a result of
their critical illness has caused physiotherapists to re-evaluate treatment priorities and include exercise rehabilitation
as a part of standard clinical practice.1
A mix of public and private health care providers delivers health care in Australia. Health care is funded nationally under a system called Medicare that covers all
Australian citizens although individuals have a choice of
opting for additional private health insurance using a private sector health provider.5 Public hospitals are directly
funded by government. Health care that includes access
to a bed, medical, nursing, allied health including physiotherapy and ancillary services is provided free of charge.
There are a relatively small number of private hospitals with
the majority of acute care and emergency beds located in
public hospitals. More complex advanced care occurs predominantly in the metropolitan public hospitals, although
increasingly, larger private hospitals are providing more
complex care including intensive care.5
Intensive care units in Australia are classified from level
one to 3 (Table 1) with level 3 being able to provide the most
advanced life support services. Units are staffed by Intensive
Care Specialists and a mix of junior and more senior medical
staff who may be involved in a speciality training program.
Nurses may have a tertiary certificate in critical care and are
staffed on a 1:1 ratio for ICU beds and 1:2 for high dependency beds where patients do not require mechanical ventilation or renal replacement therapy. The average cost of an
ICU bed is $2500-$3000 (AUD) per day and this comprises
approximately 20% of hospital expenditure.6
Most intensive care units in Australia have at least one
senior physiotherapist on staff and almost half of these
physiotherapists have greater than 5 years of critical care
experience.1,2 Whilst many have research experience in
ICU, few have research higher degrees.1,2 No specific additional training is required for physiotherapists to work in
ICU in Australia. Staffing profile is dependent on the level
of the unit based on the intensity of medical care provided,
the number of beds, and the availability of physiotherapy
staff.7 Physiotherapy services are generally provided each
day or part thereof from 0800-1700. A small number of
units have the provision for a 24 hour or after hours ser-
19
Table 1. Intensive Care Unit Levels in Australia

Level
Definition
Level 3
Must be capable of providing complex, multisystem life support for an indefinite period; must be a tertiary referral centre for patients in
need of intensive care services and have extensive back-up laboratory and clinical service facilities to support the tertiary referral role.
Must also be capable of providing mechanical ventilation, extracorporeal renal support services and invasive cardiovascular monitoring
for an indefinite period, or care of a similar nature.
Level 2
Must be capable of providing complex, multisystem life support, and be capable of providing mechanical ventilation, extracorporeal
renal support services and invasive cardiac monitoring for a period of at least several days, or longer periods in remote areas, or care of
a similar nature.
Level 1
Must be capable of providing basic multisystem life support usually for less than 24 hours. Must also be capable of providing
mechanical ventilation and simple invasive cardiac monitoring for a period of at least several hours, or care of a similar nature.
vice.7 Most physiotherapists in Australia are able to initiate

assessment and treatment without medical and/or nursing
referral as part of the multidisciplinary team.2
ROLE OF THE PHYSIOTHERAPISTS: RESPIRATORY
MANAGEMENT
The goals of respiratory physiotherapy management are to
promote secretion clearance, maintain or recruit lung volume,
optimize oxygenation and prevent respiratory complications
in both the intubated and spontaneously breathing patient.3
The Intubated Patient
Respiratory dysfunction in the intubated patient is characterised by the underlying pathology; altered respiratory
mechanics due to the effects of positive pressure ventilation, ventilation and perfusion mismatch,8 and mucociliary dysfunction.9 Patients who are intubated and ventilated
are at risk of developing secretion retention due to the disturbance of normal secretion clearance, subsequent atelectasis and ventilator associated pneumonia.9 Respiratory
physiotherapy aims to treat or prevent these sequelae using
a number of different techniques.
Manual Hyperinflation
Manual hyperinflation (MHI) has been commonly used
by Australian physiotherapists for the treatment of sputum
retention and pulmonary collapse since the early 1970s.10,11
It involves the delivery of larger than baseline tidal volumes
to a peak airway pressure of 40 cmH2O to patients who are
intubated using a manual resuscitation bag12,13 (Figure 1).
The technique is achieved by delivering a slow inspiratory
flow, followed by a 2-3 second inspiratory hold and a fast
uninterrupted expiratory flow that mimics a forced expiration.14 It has been proposed that in order to achieve the
cephalad movement of pulmonary secretions that expiratory flow must exceed inspiratory flow by more than 10%15
and be sufficient to achieve a velocity of greater than 1000
cm/second to move pulmonary secretions. The interpretation and synthesis of results of studies examining the effects of MHI have been limited by differences in definition,
dosage, and technique;3,14,18,19 nonetheless, MHI has been
consistently shown to improve static pulmonary compliance, secretion removal, reduce airways resistance, and
recruit pulmonary collapse.10,13,17,20,21,22 The dosage of MHI
reported in the literature varies from 6 cycles of 6 breaths16
to 2 cycles of 6 breaths.23
20
Figure 1. Physiotherapist performing manual

hyperinflation.
Ventilator Hyperinflation
The beneficial effects of MHI can also be achieved by
altering the settings on the patients ventilator.13,24 One of
the major advantages of performing ventilator hyperinflation (VHI) in comparison to MHI is the maintenance of
positive end expiratory pressure, and the reproducibility
of the technique.13,24 Recent survey evidence from senior
ICU physiotherapists in Australia reported that up to 39% of
ICUs use VHI, predominantly as a technique for pulmonary
secretion clearance.25 Dennis et al26 reported that VHI was
performed in both controlled and spontaneous modes of
ventilation by altering ventilatory parameters. In the spontaneous mode, VHI is achieved by incremental increases
in pressure support and in control modes by either altering
pressure or volume limits to reach a predetermined target
volume or pressure. Australian physiotherapists demonstrate broad agreement about the indications and application of VHI in clinical practice.25
Positioning
The application of both MHI and VHI is most frequently
and effectively delivered with the patient in a side lying
position with the affected lung uppermost.16,25,26 The side
lying position results in an increase in lung volume to the
uppermost lung that enhances recruitment and facilitates

drainage from broncho-pulmonary segments and depending on lung pathology, may improve gas exchange.27 Regular turning into the side lying position has also been associated with a reduction in the incidence of ventilator associated pneumonia (VAP) provided that greater than 40 of
lateral turn is achieved.28
The addition of a side lying position has been shown
to significantly increase sputum yield compared to the supine position when using MHI.26 Adding a head down tilt
in side lying has been reported to increase sputum clearance by up to 25% in our cross-over study of 20 patients
who were intubated and ventilated.16 Although there was
wide variation, the addition of a head down tilt did not
reduce peak expiratory flow which is important if we accept the theory that sufficient expiratory flow is required to
achieve movement of pulmonary secretions in the airways.
We were able to demonstrate, using an inspiratory flow obtained in a similar group of patients that the expiratory flow
produced during MHI in both the side lying and head down
tilt positions was at least 10% higher than inspiratory flow
and sufficient to produce velocities in excess of 1000 cm/
sec.16 We therefore contend that if secretion clearance is
the primary aim of treatment that a head down tilt should
be used provided no contraindications are present.
Manual Techniques
The extent and use of manual techniques by physiotherapists in ICU in Australia was last reported 10 years ago.7
At this time both chest wall percussion and vibration were
used by up to 80% of physiotherapists, often in combination with MHI.11,21 Since this time, there has been a relative
exponential increase in the research output and application
of MHI and VHI in clinical practice in Australia and the use
of manual techniques has not been reported recently.
Most research into the effectiveness of manual physiotherapy techniques has been undertaken in medical patient
populations with excessive secretion production.29 The
efficacy of chest wall percussion has not been investigated in an Australian critical care population. In contrast,
chest wall vibration in ICU has been investigated by two
Australian physiotherapists.21,30 This technique involves
the production of large and small oscillatory movements
performed during expiration that aim to increase expiratory flow and subsequent pulmonary secretion clearance.29
Stiller et al21reported that the addition of vibrations to MHI
did not further enhance the resolution of atelectasis and
Ntoumenopoulos et al31found that chest wall vibration in
combination with positioning was associated with a reduction in rates of VAP by 27%.
Suctioning
Tracheal suctioning is used during a physiotherapy
treatment to clear pulmonary secretions.8 It has been associated with episodic hypoxemia and cardiac arrhythmias31
that may have previously been attributed to the effects of
the physiotherapy treatment.32,33 The metabolic effects of a
physiotherapy treatment that included VHI, side lying and
endotracheal suctioning reported that the greatest increases

in oxygen consumption were recorded during and following the suctioning procedure.34 Whilst the instillation of
saline prior to suction remains controversial,35 it is used
selectively in clinical practice to assist in the clearance of
tenacious pulmonary secretions.
Efficacy and Safety
Multimodal respiratory physiotherapy treatment as
practiced by Australian physiotherapists has been shown to
be safe with a prospective audit of 5 metropolitan tertiary
hospitals reporting only 29 adverse physiological events
occurring in 12,800 treatments (0.22%).36 In addition
the metabolic demands of physiotherapy treatment are no
greater than turning a patient into a side lying position.34
The efficacy of prophylactic multimodal physiotherapy
treatment used in Australian ICUs in trauma populations
has been evaluated against various clinical endpoints with
conflicting results.23,30,37 The addition of MHI in a side lying position to standard nursing and medical care has
shown no significant reduction in the incidence of VAP,
the duration of mechanical ventilation or ICU length of
stay.23,37 Conversely in a heterogeneous population, the
addition of chest wall vibrations in a side lying position
was associated with a 27% reduction in VAP, although
no differences in the duration of mechanical ventilation
and ICU length of stay were observed.30 Differences in
outcomes can be explained by the different populations
and the limited sample sizes of the two studies examining
MHI. Nonetheless, these studies, in combination with the
emerging evidence to support the role of rehabilitation in
critically ill patients, have resulted in respiratory treatment
being reserved for patients presenting with atelectasis and
pulmonary secretion retention rather than as routine or
prophylactic intervention.
The Non-intubated Patient
Despite not requiring intubation or ventilation, patients
often require intensive physiotherapy treatment in the ICU.
Patients may be at risk of developing respiratory failure following extubation, admitted for routine postoperative surveillance, require treatment for postoperative pulmonary
complications, or present with hypercapnic or hypoxemic
respiratory failure requiring noninvasive ventilatory support.
In the postoperative setting physiotherapists aim to
increase lung volume using mobilization, periodic application of noninvasive ventilation (NIV), and on occasion,
deep breathing exercises.3 However, recent evidence suggests that routine respiratory physiotherapy in addition
to mobilization may be of no added benefit in reducing
postoperative pulmonary complications following major
cardiac and upper abdominal surgery.38-40 In an Australian
setting, a small study of 56 patients suggested that mobilization can reduce the incidence of pulmonary complications39 although the dose, frequency, and intensity have not
been established. A small observational study of 50 patients
reported that the time spent upright was less than 10 minutes in the first two postoperative days.41 The majority of
21
mobilization in the postoperative setting in Australia is performed by physiotherapists.41

Although the use of continuous NIV for the treatment of
hypercapnic respiratory failure and cardiogenic pulmonary
edema is supported by high level evidence,42,43the delineation of roles regarding clinical decision making and application of the apparatus between nursing, medicine, and
physiotherapy varies greatly in Australia. This is potentially
dependent on the availability of physiotherapy services, the
experience of clinicians and their seniority in the ICU.
The application of periodic continuous positive airways
pressure (pCPAP) is used by Australian physiotherapists for
the prevention and treatment of pulmonary complications
such as atelectasis. The implementation and supervision
of pCPAP is reported to be a shared responsibility between
critical care nurses and physiotherapists.7 The dosage and
interface used for the application for pCPAP by physiotherapists in the critical care setting is most likely dependent
on the severity of respiratory failure, local unit policies, and
equipment availability, although this has never been investigated.
REHABILITATION AND MOBILIZATION
The progress of intensive care medicine has resulted
in significant improvements in survival rates.44,45 Approximately 119,000 patients require admission to a general
ICU in Australia each year with survival rates around 89%
at hospital discharge.46 However, the legacy of ICU survival can be significant with prolonged immobility and catabolism resulting in deconditioning, muscle atrophy, and
weakness that may impact future health-related quality of
life.47 Reports of long-standing weakness, impaired physical function,48-50 and institutional changes to sedation and
delirium management of the critically ill51-53 have resulted
in increased interest in the provision of early rehabilitation
to patients in the ICU. The benefits and safety of rehabilitation performed in the ICU have been reported in the US
and European literature.54-56 However, to date, there is a
lack of evidence in the Australian setting. Currently in Australia at least 5 studies are being conducted or have been
recently completed examining the outcomes of ICU survivors, the efficacy of rehabilitation on physical function
and health related quality of life, and the effects of critical
illness on muscle.
In Australia many different activities are defined by the
term mobilization. These include sitting on the edge of the
bed and out of bed, marching on the spot, and walking
away from the bed.1 These activities reflect specificity of
training for functional tasks essential for independence at
hospital discharge.3 Level 3 and 4 evidence from the US
has reported that walking intubated and ventilated patients
has reduced ICU and hospital length of stay and hospital
readmission at 12 months.57,58 The pattern and dosage of
mobilization that includes walking away from the bed in
patients who are intubated in Australian ICUs is unknown
but is an area of current investigation.
Interventions used by Australian physiotherapists aimed
at maintaining muscle strength, joint range, and function
22
have been established using 3 surveys.1,2,59 The most comprehensive of these was carried out by Skinner et al.1 This
group surveyed predominantly senior physiotherapists from
126 Australian ICUs and reported that 94% of therapists
prescribe exercise routinely for long stay ICU patients.1 In
patients who were intubated and ventilated, the number
of therapists who prescribe exercise is reduced to just over
70%. Irrespective of ventilatory status, active assisted or
free active exercise was most commonly prescribed although the method to achieve this activity was varied. The
main difference in approach to rehabilitation for patients
who were intubated and ventilated was that mobilization
away from the bed was less common with only 55% of
respondents nominating it as a rehabilitation intervention
compared to over 90% for patients who were spontaneously breathing.
Adjuncts to treatment that assist the movement of patients into an upright position such as a tilt table were not
frequently used by physiotherapists.1,59 These surveys reported that whilst the tilt table was considered an option
for rehabilitation, physiotherapists preferred to use assisted
standing or marching rating the tilt table the least preferred
exercise activity1 potentially used less than once per month
or once per year.59
Historically passive limb movements have been used
by physiotherapists to maintain joint range and prevent soft
tissue contracture.4 However, recent evidence suggests
that Australian physiotherapists do not routinely prescribe
passive limb movements for the critically ill.2 In a survey
of predominantly senior physiotherapists from 51 ICUs
only one third routinely assessed joint range of movement
and 14% of respondents used passive range of movement
exercises. This number of responses may reflect the lack
of evidence to support the technique.4 Assessment of joint
range of motion was reserved for patients in whom there
was a high degree of suspicion that range may be limited
such as burns, pre-existing contracture or the presence of
increased tone.2
Evidence for the use of newer modalities by Australian
physiotherapists to assist rehabilitation such as cycle ergometry and neuromuscular electrical stimulation has not
been established. Neuromuscular electrical stimulation
has been widely established within the healthy population
to prevent muscle atrophy and minimize muscle protein
breakdown by improving oxidative metabolism.60 It has
been used with good effect in chronic inflammatory diseases, such as chronic heart failure and chronic obstructive
pulmonary diseases improving quadriceps strength, physical function, and health-related quality of life. There have
been 4 primary studies to date investigating neuromuscular electrical stimulation in the ICU population with conflicting results of effectiveness.61-64 Cycle ergometry can be
used passively or actively. A recent randomised controlled
trial examined the effect of cycle ergometry in critically ill
patients and reported improvements in quadriceps strength
and physical function at acute hospital discharge.54 However the intervention did not begin until two weeks postadmission and there were no data reporting frequency of ac-
tive versus passive cycling. It is currently unknown whether

passive cycling has any impact on muscle characteristics.
Both neuromuscular electrical stimulation and cycle ergometry are currently being evaluated in prospective randomised trials in Australian ICUs. The results of these trials
will influence future uptake of these and other rehabilitation interventions.
Outcome Measurement
A major finding of the survey of Skinner and colleagues1 was a lack of consistent outcome measurement
by physiotherapists to evaluate the effects of their exercise
intervention. Whilst the majority of physiotherapists prescribed exercise routinely for patients in ICU, only one
third of therapists used any form of outcome measure for
exercise prescription, progression, or assessment of overall
efficacy. Outcomes that were monitored for safety and exercise modification were heart rate and oxygen saturation.1
Since the results of Skinner and colleagues1 were published, the Physical Function in ICU Test (PFIT) has been
reported.65 This multidimensional test of function, strength,
and endurance has been shown to be reliable and sensitive
to change and has recently been scored. The PFIT has been
incorporated into the protocol of one international and 3
Australian trials evaluating the effects of rehabilitation on
functional outcome for critically ill patients. The clinometric properties of the test, including scoring, have been presented and are published in abstract form.66
Whilst the PFIT was designed specifically for an ICU
population, other tests of physical function have been used
to assess the functional outcome of survivors of ICU such
as the Acute Care Index of Function (ACIF), the Six Minute
Walk Test, the Barthel Index, the Functional Independence
Measure (FIM), and the Glittre Activities of Daily Living
Test.67 Both the FIM, using a sub-set of activities suitable
for an ICU population68 and the ACIF have been reported in
the ICU cohort; however, the remaining tests were developed for other medical specialities such as rehabilitation or
aged care and logistically are not suitable to be used in the
ICU setting for the prescription and evaluation of exercise.
Safety and Feasibility
There have been several international reports of the
safety and feasibility of mobilizing patients away from the
bed side who are intubated and ventilated.57,69,70 In an
Australian setting there has been one report of the safety
of mobilizing patients using specific safety criteria for initiation and progression of treatment.71 These investigators
developed a guideline based on a comprehensive patient
assessment that included the cardiovascular and respiratory
status as well as clinical reasoning to determine readiness
for mobilization. They subsequently prospectively evaluated the utility of the physiological criteria of the guideline
on 31 patients who performed 69 mobilization tasks that
included sitting on the edge of the bed, transferring out of
bed, and mobilizing on the spot and away from the bed.71
Only on three occasions (4.3%) did a patient demonstrate
clinical deterioration that required transient intervention
and on no occasion was the mobilization treatment ceased.

The guideline demonstrated good clinical utility and provides the only systematic approach to patient assessment of
readiness for mobilization although its use in clinical practice has not been reported in Australia.
The safety and feasibility of a hierarchical protocolized
exercise rehabilitation program has been reported by this
author in an Australian setting.72 As part of a larger randomised controlled trial, rehabilitation that included cardiovascular, strength and functional training was introduced on day 5 of the ICU stay; the intensity of which was
based on the results of the PFIT. These tasks were included
as they reflected Australian practice.1 Patients completed
15 minutes of exercise twice daily in the ICU with exercise progression based on Borg scores and the PFIT. Strict
safety criteria for the initiation and cessation of exercise
were used and no adverse events were recorded in 641
rehabilitation sessions. These results and those of Stiller
and colleagues71 reflect the increasing interest in the role
of mobilization and rehabilitation for critically ill patients.
Future
Mandated guidelines for the management of deteriorating patients in Australian public hospitals73 have resulted
in opportunities for physiotherapists to become increasingly involved in critical outreach teams. A multisystem
assessment and the frequent requirement for noninvasive
ventilatory support suit the skill mix of physiotherapists experienced in the care of the critically ill. This expansion of
the conventional physiotherapy role may require additional
education and acquisition of specific task related and diagnostic skills.
A commitment to research is essential for the growth
of physiotherapy in the critical care area particularly in the
role of exercise and rehabilitation. The benefits of rehabilitation for survivors of ICU in both in the short- and longterm require elucidation in randomized controlled trials.
Rehabilitation should take into consideration the cognitive
as well as physical function of the patients. Epidemiological studies to determine patients at risk for the development of longer term weakness and strategies to attenuate
and treat weakness and impaired physical function are a
priority. Further development of outcome measures that are
sensitive and valid and specifically designed for critically ill
patients are also necessary. The economic impact of ICUacquired weakness and its treatment should be assessed in
all future trials.
CONCLUSIONS
This paper describes the role of physiotherapists in critical care in Australia. While variability exists between states
and centers, as primary care practitioners, Australian physiotherapists actively treat critically ill patients targeting interventions based upon research evidence and individualized
assessment. A trend toward more emphasis on research into
exercise rehabilitation over respiratory management is now
evident. The outcomes of this developing evidence base
will shape the direction of future roles of physiotherapists
23
in the ICU and in follow up of ICU patients. It is important

that physiotherapists lead this research, formulating questions that are based upon their extensive understanding of
physical function and its importance to activities of daily
living and health related quality of life.
21.
22.
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25
What Are the Barriers to Mobilizing

Intensive Care Patients?
I Anne Leditschke, FRACP, FCIC, MMgt;1 Margot Green, Bachelor of Applied Science (Physiotherapy); 2 Joelie Irvine,
BPhysio;3 Bernie Bissett, Bachelor of Applied Science (Physiotherapy) (Hons); 4 Imogen A. Mitchell, FRCP FRACP FCICM5
Senior Specialist, Intensive Care Unit, Canberra Hospital; & Senior Lecturer, Australian National University, Canberra,
Australia, 2Senior Physiotherapist, Intensive Care Unit, Canberra Hospital; & Physiotherapy Department, Canberra Hospital,
Canberra, Australia, 3Cardiorespiratory Physiotherapist, Physiotherapy Department, Canberra Hospital, Canberra, Australia
4
Clinical Educator, Physiotherapy Department, Canberra Hospital; & University of Queensland, Australia, 5Director, Intensive
Care Unit, Canberra Hospital; and Associate Professor, Australian National University, Canberra Australia
1
ABSTRACT
Purpose: Recently there has been increased interest in early
mobilization of critically ill patients. Proposed benefits include improvements in respiratory function, muscle wasting, intensive care unit (ICU), and hospital length of stay.
We studied the frequency of early mobilization in our intensive care unit in order to identify barriers to early mobilization. Methods: A 4-week prospective audit of 106 patients
admitted to a mixed medical-surgical tertiary ICU (mean
age 60 20 years, mean APACHE II score 14.7 7.8) was
performed. Outcome measures included number of patient
days mobilized, type of mobilization, adverse events, and
reasons for inability to mobilize. Results: Patients were mobilized on 176 (54%) of 327 patient days. Adverse events
occurred in 2 of 176 mobilization episodes (1.1%). In 71
(47%) of the 151 patient days where mobilization did not
occur, potentially avoidable factors were identified, including vascular access devices sited in the femoral region, timing of procedures and agitation or reduced level of consciousness. Conclusions: Critically ill patients can be safely mobilized for much of their ICU stay. Interventions that
may allow more patients to mobilize include: changing the
site of vascular catheters, careful scheduling of procedures,
and improved sedation management.
Key Words: intensive care units, mobility, physical therapy
INTRODUCTION AND PURPOSE
In many intensive care units, it has been usual practice
to manage critically ill patients with deep sedation and bed
rest.1 However, an increasing body of literature has documented the complications associated with bed rest, which
affect virtually every body system.2-5 Much recent attention
has focused on intensive care unit (ICU)-acquired weakness
Address correspondence to: I Anne Leditschke, FRACP,

FCICM, MMgt, Intensive Care Unit, Canberra Hospital,
Canberra, ACT Australia 2605, Ph: +61 2 6244 3103,
Fax: +61 2 6244 3507 (Anne.Leditschke@act.gov.au).
26
and the long-term adverse functional sequelae for ICU survivors, particularly in the physical domain6,7 and this has led
to an increased interest in early mobilization in the ICU as
a potential means of prevention. Proposed potential benefits of early mobilization of critically ill patients include
improvements in respiratory function, reduced muscle wasting, decreased ICU and hospital length of stay, and reduced
readmission and mortality for 12 months postdischarge.8-11
We have been pursuing a strategy of reduced sedation
and active mobilization in our ICU for approximately 10
years.12 Unless deep sedation is required for a clear medical indication, such as the management of intracranial
hypertension following traumatic brain injury, sedation in
our ICU is managed with a nurse-controlled sedation algorithm, titrated to a goal Riker Sedation Agitation Scale13
of 4, which is a calm, alert, and cooperative patient. Analgesia is managed with patient-controlled analgesia where
possible, and nurse controlled analgesia when this is not
possible. In order to assess the frequency of early mobilization in our ICU and to identify barriers to early mobilization, we performed a quality audit.
METHODS
Participants
A 4 week prospective audit of usual practice was conducted on all 106 patients present in a mixed medical-surgical tertiary ICU during a 4 week period in October-November
2008. Mean age was 60 (SD 20) years, and mean APACHE
II score14 was14.7 (SD 7.8). Of the 106 patients admitted,
70 (66%) were male, with surgical postoperative admissions
in 47 patients (44%) and trauma admissions in 14 patients
(13%). Median ICU length of stay was one (range 1-198) day,
and median hospital length of stay was 12.5 (range 1-454)
days. The study was approved by the relevant Canberra Hospital Executive as a quality audit and has been approved by
the Australian Capital Territory Human Research Ethics Committee as a Low Risk Study (ETHLR.11.225).
Mobilization techniques
The mobilization techniques used were classified into
3 groups:
1. Active mobilization was defined as marching on the

spot for > 30 seconds or mobilizing away from the bedspace (Figure 1A).
2. Active transfer was defined as active transfer from bed
to chair where the patient assists with transfer against
gravity (Figure 1B).
3. Passive transfer, where a lifter, sling, or other device
is used to transfer a patient out of bed, with minimal
patient assistance with the transfer (Figure 1C).
Data collection
De-identified data were collected on the number of patient days mobilized, type of mobilization, adverse events,
and reasons for inability to mobilize as follows. For each day
during the audit period, the physiotherapist assigned to the
ICU on that day recorded the number of patients in the ICU
on that day. For each patient for that day, whether they were
mobilized and the type of mobilization, any adverse events
and reasons for inability to mobilize was also recorded. If
there were multiple reasons for inability to mobilize in a single patient, a judgement was made about the most important
reason for not mobilizing. For example, a patient who was
hemodynamically unstable and was medically required to
rest in bed because of a fractured pelvis would be classified
as unable to mobilize due to medical orders.
Additional data collected by the physiotherapist prospectively included demographic data (age and gender)
and admission diagnosis. This was compared for accuracy
with the de-identified data routinely collected for quality
purposes as part of our contribution to the Australian and
New Zealand Intensive Care Society (ANZICS) Adult Patient Database15. Severity of illness (APACHE II14) scoring
for the audit period was obtained from the de-identified
data routinely collected for quality purposes as part of our
contribution to the database, and was calculated using ANZICS AORTIC software, version 7.0.16
Outcome Measures
A patient day was counted for each day that a patient
was in the ICU during the audit. For each patient day, type
of mobilization, adverse events, and reasons for inability to
mobilize were recorded.
RESULTS
Frequency of mobilization
There were 327 patient days during the audit period.
Ventilated patient days accounted for 155 (47%) of these.
Although 47 (44%) of the 106 patients present in the ICU
unit during the audit period were postoperative surgical patients, only 54 (17%) of the 327 patient days audited were
postoperative patient days, presumably because these patients had shorter ICU length of stay.
Patients were mobilized on 176 (54%) of the 327
patient days audited. Figure 2 demonstrates the proportions of different types of mobilization that occurred,
and the impact of mechanical ventilation on mobilization overall and mobilization techniques used. Active
mobilization occurred in 76 patient days (23%) and
active transfer in 40 patient days (12%). Of these 116
patient days, 20 (17%) involved patients who were mechanically ventilated. Passive transfer was the mobilization method used for 60 patient days and 40 (67%) of
these passive transfer days involved mechanically ventilated patients. Of the 106 patients in the audited period,
11 (10%) underwent passive transfer, 28 (26%) active
transfer, 36 (34%) active mobilization, and 31 (29%) remained resting in bed.
Adverse events
There were two adverse events recorded in 176 mobilization episodes (1.1%). Both episodes involved hypotension requiring intervention (return to bed, fluid loading,
and transient increase in vasopressor requirements).
Figure 1. Mobilization methods. A. Active mobilization (left frame). B. Active transfer (middle frame). C. Passive transfer (right frame).
27
Figure 3. Frequency of barriers to mobilization

The number of patient days that patients were not
mobilized is shown for each categeory of reason for nonmobilization both ventilated and nonventilated patient
days with the frequency of each reason recorded. GCS:
Glasgow Coma Score.
Figure 2. Mobilization methods and ventilation status.

Top: Relative frequencies of each mobilization method.
Patients were mobilized out of bed via passive transfer,
active transfer, or active mobilization. Patients not
mobilized remained in bed.
Barriers to mobilization
Figure 3 is a frequency histogram of the reasons that
patients were not mobilized, for both ventilated and nonventilated patient days. Reasons for inability to mobilize included potentially avoidable factors in 47% of the patient
days surveyed. These included vascular access catheters in
a femoral position in 32 patient days, timing of procedures
in 18 patient days, sedation management in 12 patient days
(agitation in 9 patient days and low Glasgow Coma Score in
3 patient days) and early ward transfer in 9 patient days. Of
the unavoidable factors preventing mobilization, respiratory
instability was the most frequent, accounting for 20 patient
days, followed by hemodynamic instability for 17 patient
days, neurologic instability (difficult to control intracranial
hypertension) for 15 patient days, and medical orders to rest
in bed (for pelvic fractures or similar indication)15 patient
days. Other unavoidable factors occurred in13 patient days.
28
DISCUSSION
We undertook this audit to assess our performance in
mobilizing patients and to record reasons patients were
not mobilized in an attempt to identify modifiable factors.
We were surprised that only 54% of patient days involved
mobilization, as we expected the proportion of mobilized
patient days to be higher than this, but these results are
consistent with the critical care nutrition literature, where
underfeeding, despite a perception of adequate feeding, is
common.17 This is also consistent with physiotherapy evidence regarding mobilization of postoperative abdominal
surgery patients, where amount of time out of bed was
found to be low18 despite evidence that early physiotherapy
reduces postoperative pulmonary complications.19 However our mobilization rate compares favorably to the two recent prospective randomized controlled trials of early mobilization in critically ill patients, in which fewer than 10%
of screened patients were enrolled.8,9 Although both studies suggested that mobilization therapy was beneficial, the
low enrollment to screening ratio casts some doubt on the
generalizability of these results to the critical care patient
population. The very low occurrence of adverse events in
our study is consistent with other published studies, which
have reported no adverse events or adverse event rates of
less than 1%.8-10,20-22 Specifically, we were able to mobilize
ventilated patients with both passive and active mobilization techniques, and find it surprising that anecdotally some
ICUs are still reluctant to mobilize these patient groups despite the low risks20,21 and potential benefits.
It is of note that in almost half of the patient days where
mobilization did not occur, mobilization would have been
possible with relatively simple changes in management,
such as selection of site for vascular access devices, timing
of procedures and improved sedation management. As early
mobilization has been shown to be the key component of
physiotherapy intervention for reducing postoperative pulmonary complications in high risk patients23 and recent evidence suggests that a critical care early mobilization program
reduces the risk of death or hospital readmission within 12
months of discharge,11 it would seem imperative that all reversible obstacles to early mobilization should be addressed.
While the most effective method of implementing an early
mobilization program in the ICU is yet to be determined, we
believe that a multidisciplinary team approach including active collaboration between physiotherapy, nursing and medical staff is likely to be the most effective. Whatever model
is used, active identification of barriers to mobilization and
active planning to avoid these issues should be included as
part of the mobilization strategy.
CONCLUSIONS
In summary, we have demonstrated that in our intensive
care unit patients are mobilized more than 50% of patient
days, and that this high frequency of mobilization is safe. In
addition, we have identified a number of relatively simple
interventions that may allow more patients to mobilize, include changing the site of vascular access devices, careful
scheduling of procedures, and improved sedation management. Further studies investigating the impact of strategies
to address these issues are recommended.
REFERENCES
1. Needham DM. Mobilizing patients in the intensive
care unit: improving neuromuscular weakness and
physical function. JAMA. 2008;300:1685-1690.
2. Truong AD, Fan E, Brower RG, Needham DM. Benchto-bedside review: mobilizing patients in the intensive
care unit--from pathophysiology to clinical trials. Crit
Care. 2009;13:216.
3. Teasell R, Dittmer DK. Complications of immobilization and bed rest. Part 2: Other complications. Can
Fam Physician. 1993;39:1440-1442, 1445-1446.
4. Dittmer DK, Teasell R. Complications of immobilization
and bed rest. Part 1: Musculoskeletal and cardiovascular complications. Can Fam Physician. 1993;39:14281432, 1435-1437.
5. Pavy-Le Traon A, Heer M, Narici MV, Rittweger J,
Vernikos J. From space to Earth: advances in human
physiology from 20 years of bed rest studies (19862006). Eur J Appl Physiol. 2007;101:143-194.
6. Herridge MS. Building consensus on ICU-acquired
weakness. Intensive Care Med. 2009;35:1-3.
7. Cuthbertson BH, Roughton S, Jenkinson D, Maclennan
G, Vale L. Quality of life in the five years after intensive
care: a cohort study. Crit Care. 2010;14:R6.
8. 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;373:1874-1882.
9. 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.
10. 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;36:2238-2243.

failure. Am J Med Sci. 2011; 34:373-377.
12. Feeley K, Gardner A, Mitchell I, Leditschke A. Does
implementation of a goal sedation score improve management of mechanically ventilated adults? Crit Care.
2005,9(Suppl 1):P141.
13. Riker RR, Picard JT, Fraser GL. Prospective evaluation
of the Sedation-Agitation Scale for adult critically ill
patients. Crit Care Med. 1999; 27:1325-1329.
14. Knaus WA, Draper EA, Wagner DP, Zimmerman JE.
APACHE II: a severity of disease classification system.
Crit Care Med. 1985;13:818829.
15. Stow PJ, Hart GK, Higlett T, et al. Development and
implementation of a high-quality clinical database: the
Australian and New Zealand Intensive Care Society
Adult Patient Database. J Crit Care. 2006;21:133-141.
16. AORTIC software. http://www.anzics.com.au/core/aortic-software. Accessed October 17, 2011.
17. Martin CM, Doig GS, Heyland DK, et al. Multicentre, cluster-randomized clinical trial of algorithms for
critical-care enteral and parenteral therapy (ACCEPT).
CMAJ. 2004;170:197-204.
18. Browning L, Denehy L, Scholes RL. The quantity of
early upright mobilisation performed after upper abdominal surgery is low: an observational study. Aust J
Physiother. 2007;53:4752.
19. Chumillas S, Ponce JL, Delgado F, Viciano V, Mateu M.
Prevention of postoperative pulmonary complications
through respiratory rehabilitation: A controlled clinical
study. Arch Phys Med Rehabil. 1998;79:59.
Care Med. 2007;35:139-145.
21. Pohlman MC, Schweickert WD, Pohlman AS, et al. Feasibility of physical and occupational therapy beginning
from initiation of mechanical ventilation. Crit Care
Med. 2010;38:2089-2094.
22. 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;53:279283.
23. Mackay MR, Ellis E, Johnston C. Randomised clinical
trial of physiotherapy after open abdominal surgery in
high risk patients. Aust J Physiother. 2005;51:151159.
29
Physical Therapy Management of a Patient on Portable

Extracorporeal Membrane Oxygenation
as a Bridge to Lung Transplantation: A Case Report
John D. Lowman, PT, PhD, CCS;1 Tamara K. Kirk, PT, CCS;2 Diane E. Clark, PT, DScPT, MBA1
University of Alabama at Birmingham, Department of Physical Therapy, Birmingham, AL
Duke University Hospital, Department of Physical and Occupational Therapy, Durham, NC
1
ABSTRACT
Introduction: Although the life expectancy for patients with

cystic fibrosis (CF) has increased dramatically in the preceding decades, often the final therapeutic option for patients
with end-stage CF is lung transplantation. Prior to transplantation, patients with severe disease may require mechanical
ventilation. Those refractory to mechanical ventilation may
require extracorporeal membrane oxygenation (ECMO). The
purpose of this case report is to describe the physical therapy
management of a patient who received ECMO as a bridge
to lung transplantation. Case Presentation: A 16-year-old
girl with severe acute respiratory failure due to a CF exacerbation eventually required ECMO to maintain adequate gas
exchange. While on ECMO, she received physical therapy
interventions ranging from therapeutic exercise, manual
therapy, and integumentary protection techniques in addition to airway clearance techniques. Prior to her transplant,
she was standing multiple times per day with moderate assistance, was sitting on the edge-of-bed, as well as taking
steps to transfer to/from a chair. She successfully received a
bilateral lung transplant after 8 days on ECMO. Conclusion:
Physical therapy interventions, including out-of-bed mobility, can be safely provided to patients on portable ECMO as
a bridge to lung transplantation. These interventions were
focused on preventing the negative sequelae of bed rest, increasing her strength and endurance, as well as improving
her level of consciousness and psychological well being in
preparation for lung transplantation.
Key Words: extracorporeal membrane oxygenation, lung
transplantation, physical therapy, exercise
BACKGROUND AND PURPOSE
Cystic fibrosis (CF) is no longer a disease of children;

projected life expectancy for patients with CF has increased
Address correspondence to: John D. Lowman, PT,
PhD, CCS, University of Alabama at Birmingham, Department of Physical Therapy, 344 School of Health
Professions Building, 1530 3rd Avenue South, Birmingham, AL 35294 (jlowman@uab.edu).
30
into the late 30s, and continues to grow. The genetic defect,
affecting the cystic-fibrosis transmembrane conductance
regulator (CFTR), leads to mucosal obstruction in multiple
tissues, especially the lung. Associated lung pathology is
the primary contributor to mortality in patients with CF.1
Treatment of the pulmonary involvement typically includes
inhaled medications [eg, hypertonic saline, tobramycin (an
antibiotic), and dornase alfa (a mucolytic)], systemic antibiotics, airway clearance, and exercise.2 As the disease progresses, pulmonary exacerbations become more frequent
and severe and are associated with increased morbidity
and mortality.3 Although there are many new exciting therapies for CF in the pipeline,1,2 for patients with frequent
exacerbations and severe disease, lung transplantation is
often the final therapeutic option.2
Cystic fibrosis is the third leading indication for lung
transplantation.4 Although transplantation of patients on mechanical ventilation was previously discouraged, the current
US lung allocation system assigns high scores to ventilatordependent patients, since they have a high medical urgency.4 Patients with CF who undergo lung transplantation have
similar outcomes whether they are mechanically ventilated
or nonmechanically ventilated at the time of transplantation.5 Another potentially controversial group for lung transplantation are patients requiring preoperative extracorporeal
membrane oxygenation (ECMO).4 Although the early postoperative risk of death is almost 2.6 times higher in patients
requiring ECMO prior to lung transplant compared to the unsupported patient, survival after 9 months is fairly similar.6
Extracorporeal membrane oxygenation is used to maintain adequate gas exchange in patients with severe respiratory failure that is refractory to even maximal mechanical
ventilatory support, including patients who are waiting for
a lung transplant. Most patients on ECMO are sedated and
on bed rest, but there are a few reports of ambulatory patients on ECMO as a bridge to lung transplantation.7,8 If
ECMO is to be a successful bridge to lung transplantation,
then prevention of the many sequelae of bed rest and a
continuation of pretransplant rehabilitation is needed.
The purpose of this case report is to describe the physical
therapy management of a patient who received ECMO as a
bridge to lung transplantation. Consent of the patient and
permission of her family were provided to present the case.
CASE DESCRIPTION
Jane, a 16-year-old female with CF, was admitted to

a tertiary-care childrens hospital for worsening shortness
of breath. Over the next week, her condition continued to
deteriorate until she eventually went into severe respiratory
failure, requiring mechanical ventilation. The following
day Jane was transferred to the pediatric intensive care unit
(PICU) at our hospital for management of her respiratory
failure and evaluation for lung transplantation (hospital day
[HD) 0]. On admission, her respiratory failure was refractory to traditional mechanical ventilation (see Table 1), and
required that she be placed on a high-frequency percussive ventilator [(The Percussionaire VDR-4) with peak
inspiratory pressure 30 cm H2O, frequency 510 cycles/min,
inspiratory time 3.0 sec, positive end expiratory pressure
(PEEP) 10 cm H20, FiO2 1.00]. The high-frequency percussive ventilation improved her hypercapnia and acid-base
balance, but did little for her oxygenation (Table 1).
Cardiovascular and pulmonary examination revealed

mild sinus tachycardia (90-110 bpm) of normal rhythm (per
EKG) and a blood pressure ranging from 90-125/64-74 mm
Hg (per arterial BP monitor); her respiratory frequency was
ventilator dependent (as noted above) and SpO2 ranged
from 95% to 97%. The high-frequency percussive ventilator precluded performance of a valid chest examination
due to the excessive noise and vibration from the ventilator.
She also had severe digital clubbing and 4+ pitting edema
in her right foot. Her skin was dry, but intact and without
evidence of excessive pressure.
Shoulder flexion and abduction were limited bilaterally
to ~150 and 120, respectively; otherwise, her upper extremity range of motion (ROM) was normal. Lower extremity ROM and flexibility were normal with the exception
of ankle dorsiflexion to neutral with her knees extended.
Muscle bulk was quite diminished. She was hypotonic but
demonstrated right greater than left ankle clonus.
Table 1. Arterial Blood Gas Values

Hospital day
FiO2
pH
1.00
7.09
pCO2
(mm Hg)
pO2
(mm Hg)
HCO3
(mmol/L)
SaO2
(%)
PaO2/FiO2
187
63
54
87.8
63
High-frequency jet ventilation initiated

1
0.85
7.30
102
63
49
91.3
74
0.70
7.28
94
68
42
93.1
97
ECMO initiated
7
0.45
7.56
40
42
35
86.3
93
0.35
7.46
49
83
35
96.3
237
11
0.35
7.47
51
77
36
95.7
220
14
0.35
7.40
57
70
34
91.9
200
Bilateral lung transplant

16
0.21
7.55
32
91
28
94.8
433
19
0.21
7.54
37
75
32
93.8
357
Past Medical History

Over the course of the past year, Jane had repeated lung
infections requiring repeated intravenous (IV) antibiotics.
Her last exacerbation was 3 months prior to this episode.
Jane was also pancreatic insufficient and had lost approximately 14 kg (30 lbs) over the last several months. Her
family reported that she had been active and fairly athletic
until her recent exacerbations.
Physical Examination (Hospital Day 6)
Physical therapy was consulted on HD 6, while Jane
was in the PICU sedated and nonresponsive. On observation, she was on mechanical ventilation via oral endotracheal tube, and connected to a left radial arterial
line, left brachial double-lumen peripheral-inserted central catheter, two right peripheral intravenous catheters,
naso-gastric tube, Foley catheter, pulse oximeter, and
ECG monitor. Her body mass and height were 38 kg (84
lbs) and 152.5 cm (50) respectively, giving her a BMI of
16.3 kg/m2.
Clinical Impression
Jane was severely hypercapnic, requiring high levels of
mechanical ventilation, high FiO2, and medical sedation.
Given her current medical status, we did not address any
activity goals at this time. Rather, we focused our goals on
preventing anticipated problems9 associated with bed rest
and immobility such as joint contractures at the shoulder,
elbow, hip, knee, and ankle that can limit activity and often persist through discharge from the hospital.10 Pressure
sores also frequently occur in the ICU. Underweight patients, like Jane, have a 5-fold greater risk for developing
pressure sores primarily at the sacrum and heel.11,12
Interventions (HD 6)
Initial interventions included passive range of motion
(PROM) to all major upper and lower extremity joints, stretching of plantar flexors, and application of pressure relieving
ankle foot orthoses (PRAFO) to maintain the feet in neutral
dorsiflexion, hip in neutral rotation, and keep her heels elevated off the bed (Table 2). Airway clearance was not a PT
31
Table 2. Medication List on Initial Examination (HD 6)

Drug (trade name)
Drug class
tobramycin
aminoglycoside antibiotic
meropenem
carbapenem antibiotic
cefepime
cephalosporin antibiotic
ciprofloxacin (Cipro)
fluoroquinolone antibiotic
vancomycin
glycopeptide antibiotic
voriconazole (Diflucan)
triazole antifungal
midazolam (Versed)
anxiolytic-sedative
(benzodiazepine)
methylprednisolone
(Solu-Medrol)
corticosteriod
pancrelipase (Ultrase)
digestive enzyme
ketamine
general anesthetic
famotidine (Pepcid)
histamine-2 blocker
intervention as respiratory therapy administered intrapulmonary percussive ventilator treatments every 4 hours.13
Re-examination (HD 7)
Despite high FiO2 and high-frequency percussive ventilation, Jane remained significantly hypoxic and hypercapnic (see
Table 1) resulting in her placement on veno-venous ECMO via
double lumen cannulation of the right internal jugular vein, as
well as placement on the lung transplantation list (HD 6). On
the morning of HD 7, she received a tracheostomy and was
converted to synchronized intermittent mechanical ventilation (tidal volume 4.2 ml/kg, frequency 16 breaths/min, PEEP
10 cm H2O, FiO2 0.45) with much improved gas exchange
(see Table 1). She remained medically sedated.
Interventions (HD 7-8)
Janes physicians were consulted regarding her ability to
participate in physical therapy now that she was on ECMO.
Given that Janes pulmonary status was stabilized, the physicians planned to decrease her sedation to allow her to
progress to active exercise and begin mobility training.
Janes right upper extremity ROM was limited to prevent
placing stress on her internal jugular catheters, but this did
not preclude glenohumeral joint mobilization. In addition,
active assistive ROM was begun as she became more alert.
Consults for occupational therapy (OT) and speech therapy
were recommended as Jane attempted to mouth words but
became frustrated with her inability to communicate.
Re-examination (HD 9)
Team discussions resulted in agreement that the goal
for Jane would be that she would be cognitively alert and
weight bearing/ambulatory prior to receiving a lung transplant. While Jane was awake and following commands,
she remained lethargic. She had gross muscle atrophy
consistent with strength of ~2/5 in all key upper and lower
extremity muscle groups, but her strength diminished with
multiple repetitions. She was able to maintain stable vital
signs when positioned in a semi-upright position (bed in
the chair position).
32
Clinical Impression
Janes most significant impairments included decreased
muscle strength, power, and endurance that limited her
ability to perform simple bed mobility tasks such as rolling,
bridging, or scooting in bed. Goals included sitting edge
of bed without assistance and transferring from bed to chair
and walking in the room with assistance.
Interventions (HD 9-14)
Janes PT interventions are described in Table 3, which
included a progression from active exercises in bed, to resistive and task-specific exercise as Jane improved in strength
and endurance. She sat up with the in bed in the chair
position (~60) twice on HD 9 with PT, OT, nursing, and
respiratory therapy. From sitting upright with the bed in
the chair position, Jane was then able to sit on the edgeof-bed (HD 10) (Figure 1). She initially required maximal
assistance for sit-to-stand (HD 11) but was able to come to
stand with moderate assistance, and maintain standing with
minimum assistance. As she progressed, the interventions
were progressed to having Jane perform higher numbers of
repetitions of the tasks and to maintain upright sitting and
standing for longer periods of time. In addition, PT and OT
continued to provide PROM and joint mobilization as well
as active assistive ROM exercises in sitting.
Clinical Impression
Continued close attention was paid to any signs and
symptoms of poor cardiac output, including orthostatic intolerance (decreasing arterial BP or SpO2, increased HR,
diaphoresis, pallor, and complaints of dizziness, fatigue,
or shortness of breath) as well as ensuring the integrity of
the ECMO cannula. Also, a respiratory therapist continuously monitored her ECMO flow. Even in response to vertical postures (sitting and standing), there were never any
instances in which either her ECMO flows diminished or
she appeared to have inadequate systemic oxygen delivery.
Figure 1. Jane sitting edge-of-bed on HD 11 with PT and

a respiratory therapist in the foreground and another
respiratory therapist and nurse behind her.
Table 3. Summary of Physical Therapy Episode of Care

HD
Key examination findings
Physical Therapy Interventions
Medically sedated and non responsive
PROM to all major upper extremity (UE) and lower extremity (LE) joints, stretching of plantar flexors,
and application of pressure relieving ankle foot orthoses (PRAFO) for positioning and pressure relief.
ECMO initiated
7
Medically sedated, now on ECMO,

SIMV, and s/p tracheostomy
PROM continued, mother instructed in PROM and donning/doffing the PRAFOs. Right glenohumeral
joint mobilization.
Awake, mouthing words
Active assistive range of motion (AAROM) of all major UE and LE muscle groups. Recommendation
for speech therapy and occupational therapy consults.
Awake and following commands, but

lethargic. Bleeding from trach site.
Bilateral UE and LE muscle strength
~2/5
AM: Patient sat up with the bed in the chair position (~60) for ~10 min. AAROM in sitting.
PM: Sitting with bed in chair position for ~15 min. Bilateral planar flexor stretches, active assisted
ankle, knee, and hip flexion and extension while in sitting.
10
Alert, ready to sit up. Brief complaint of

dizziness, in sitting, but MAP 87-93 mm
Hg, HR 80-90 bpm, and SpO2 92-95%
on FiO2 0.35. Knee extensor strength
3-/5.
Transfer from supine to sitting edge-of-bed (EOB) with maximal assistance (2 persons to assist the
patient and 3 more to guide her ventilator tubes, ECMO cannulae, and other arterial and venous
lines). Minimal/moderate assistance required to maintain upright sitting (more as patient fatigued). Sat
edge of bed for ~40 min, intermittently performing UE and LE AAROM.
11
Eager to sit and stand. No adverse signs

or symptoms related to intervention
except pain at trach site and fatigue at
end of session (MAP 90-108 mm Hg,
HR 68-95 bpm, , SpO2 mid-90s).
UE and LE AAROM in supine. Transferred to EOB with maximal assistance. Sat EOB for 15 min with
contact guard-to-minimal assistance (see Fig 1). Worked on weight shifting, reaching and scooting
while in sitting. She stood twice with maximal assistance (15 to 20 sec each). Knees did not buckle in
standing, but she required assistance to stand erect, presumably due to hip extensor weakness.
12
AM: Anxious and medically sedated

PM: Drowsy but motivated.
Transferred to EOB with maximal assistance. Stood twice with maximal assistance, but was able to
remain standing for almost 2 min each time. Required assistance to block her knees and help facilitate
hip extension.
13
14
Stood twice for 60-90 sec. Required only moderate assistance for sit-to-stand, then only minimal
assistance to maintain standing. Sat EOB ~45 min with contact guard/minimal assistance. Performed
active (gravity resisted) UE and LE exercises in sitting.
Off ventilator, on trach collar trial for
first time (FiO2 0.40). No complaints of
trach site pain, dizziness, or dyspnea.
Patient excited to be out of bed. Vital
signs stable throughout.
Sit-to-stand with moderate assistance. Practiced weight shifting in standing. Took 5 steps from
bed and pivoted to sit in chair for the first time. Repeated 2 more sit-to-stand trials, with standing
durations of ~45 sec. Sat upright in chair for ~30 min and then with feet elevated for another 90 min.
Transferred back to bed, again taking 5-6 steps.
Bilateral lung transplant
OUTCOME
Jane received a bilateral orthotopic lung transplant on
HD 15. When seen by PT on postoperative day 2 (HD
17), she was already off the ventilator breathing humidified room air (FiO2 0.21) through a trach collar, started taking her first steps the following day (HD 18), and was discharged from the ICU on postoperative day 7 (HD 22). By
hospital discharge (HD 45), she was walking over 365 m
independently on room air with SpO2 96% with minimal
dyspnea and no pain.
DISCUSSION
Several recent articles in the physical therapy literature

have discussed the feasibility and safety of providing PT interventions, including out-of-bed mobility, for patients with
invasive lines, tubes, monitors, and cardiac support devices.14-18 This case demonstrates that patients on ECMO may
be safely mobilized by physical therapy and benefit from
physical and occupational therapy in the pretransplantation phase that may include mechanical ventilation and
ECMO. While this is not the first case report of ambulatory

ECMO used as a bridge to lung transplantation,7,8 it appears
to be the first pediatric case, the first in a patient with CF,
and the first to describe the physical therapy management
of a patient on ECMO. Two additional patients at our facility with CF and acute respiratory failure have recently been
successfully mobilized out-of-bed with portable ECMO
prior to lung transplantation, with one patient walking over
200 m less than two weeks after being placed on ECMO.
Continuous Examination
Due to the severe acuity of Janes condition, every PT
session was a re-examination. Typically, she had improved
since the last visit and the intervention could be progressed,
but often her condition had worsened or other complications had developed (eg, bleeding or anxiety), requiring a
change in plans. Even during the course of a session, her
response to exercise and activity was continuously monitored by the team to ensure she was hemodynamically stable and safe. All of the PTs and OTs involved in her care
had extensive experience working with critically ill patients
33
and were accustomed to being flexible, prepared for the

unexpected, and able to think on their feet as they continuously re-examined her response to treatment.
Interventions and Rationale
Often patients in the ICU are seen as lower priority
patients, but this attitude may be changing.19 Since the
medical team wanted to make sure she was cognitively and
physically able to participate in post-transplant rehabilitation, Jane was considered a high priority patient, receiving
12 physical therapy sessions during her 8 days on ECMO
prior to receiving her lung transplant. As seen in Figure 1,
Jane required the assistance of numerous health care professionals during mobility activities. The interdisciplinary
team spent additional time coordinating schedules to accommodate nursing and respiratory therapy interventions.
Specific physical therapy interventions ranged from
therapeutic exercise, manual therapy, and integumentary
protection techniques to airway clearance techniques. As
noted in Table 3, therapeutic exercise encompassed the
bulk of interventions. As soon as Jane was able, we progressed her exercises from active exercise in bed, to resistive, task-specific performance training to increase her
lower extremity strength, power, and endurance. Since
she initially (HD 11) required maximal assistance for sit-tostand, this represented high-intensity resistance training
for her lower extremity extensors. As she became stronger
and required less physical assistance to stand, her relative
intensity of resistance training was lower, allowing us to
increase the number of repetitions and increase her muscular and cardiovascular endurance.
Sitting upright, initially with the bed in the chair position, and then later sitting on the edge-of-bed benefitted Jane by allowing her to maximize ventilation/perfusion
matching, ease her work of breathing, and mobilize her
secretions.20 Sitting on the edge-of-bed was also a therapeutic exercise that strengthened Janes core/trunk muscles
and improved balance while reconditioning her cardiovascular system by being in a more vertical posture.20 Continued close attention was paid to any signs and symptoms
of poor cardiac output, including orthostatic intolerance
(ie, decreasing arterial BP; increased HR; decreasing SpO2,
diaphoresis, pallor, and complaints of dizziness, fatigue, or
shortness of breath).
We did not specifically work on rolling in bed and
supine-to-sit transfers. In order to protect the ECMO cannula and reduce sheer stress on her sacrum while moving
in bed, the transition from supine to sit was a maximal assist to dependent transfer. Also in an effort to protect the
ECMO cannula while maintaining or increasing glenohumeral capsular extensibility, joint mobilization was substituted for full shoulder PROM on the right.
Airway clearance is always a concern in patients with
CF. In this case, an intervention, intrapulmonary percussive
ventilation, with similar efficacy of postural drainage, percussion, and vibration,13 was provided by respiratory therapy on
a frequent basis throughout the day. This allowed PT to concentrate on exercise interventions, which often required 60
34
to 90 minutes per day. In addition, the upright positioning,

spontaneous deep breathing that occurred during physical
activity, and coordinated deep breathing with upper extremity exercise provided a stimulus for mobilization of secretions.
Potential Medical Complications
Although thrombus and infection are also risks of venovenous ECMO, bleeding and decannulation are the major
concerns when mobilizing patients on ECMO.21 Jane did
have several episodes of bleeding at her tracheostomy site
that disrupted her therapy schedule. During mobility interventions, great care was taken by the interdisciplinary team
to manage her tubing to prevent tension from being placed
on either her internal jugular cannula or her tracheostomy
tube that could have further exacerbated her bleeding or
led to decannulation.
Although Jane was not specifically diagnosed with a
critical illness myopathy and/or neuropathy, neuromuscular abnormalities occur in approximately 50% of patients
requiring prolonged mechanical ventilation, is more common in women, and may be associated with glucocorticoid
use.22 Although her daily dose of methylprednisolone (20
mg per day) was not excessively high, glucocorticoids can
impair muscle function by increasing protein degradation
and decreasing protein synthesis,23 and could have resulted
in her significantly impaired muscle strength.
CONCLUSION
There is increased interest in early mobilization for patients in the ICU.24,25 We report on a novel population of
patients who benefit from PT in the ICU, those on portable ECMO. As portable ECMO becomes a more common
bridge to lung transplantation, mobilization of patients in
the ICU while on ECMO will be needed to maintain or
increase patients physical function and psychological
well-being while awaiting transplantation. This case demonstrates that a coordinated, interdisciplinary team effort
can be safely used to meet these goals of patients on ECMO
awaiting lung transplantation.
ACKNOWLEDGEMENTS
We thank our willing and dedicated patient and her
family for blazing a new path for the many patients that
will continue to follow in her footsteps at our facility and
around the world. Her success was made possible by an
innovative and committed interdisciplinary team of physicians, surgeons, nurses, respiratory therapists, occupational
therapists, and physical therapists. In particular, we would
like to thank the therapists from the Department of Physical
and Occupational Therapy that frequently saw Jane: Whitney Diebolt, OTR/L; Erin Diebold, PT, DPT; Bethany Yoder,
PT, DPT; and Heidi Pongracz, PT, MPH, as well as David
Zaas, MD, MBA, Medical Director of Lung Transplantation,
Duke University Health System.
This work was supported by the Cystic Fibrosis Foundation (RDP464) and the National Institutes of Health (P30
DK072482).
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KC. Lung transplantation for cystic fibrosis: current
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cystic fibrosis. Pediatr Pulmonol. 1995;20(1):50-55.
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2000;11(1):16-25.
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35
Using Simulation and Patient Role Play

to Teach Electrocardiographic Rhythms
to Physical Therapy Students
Nancy Smith, PT, DPT, GCS; Sharon Prybylo, PT, DPT; Teresa Conner-Kerr, PT, PhD, CWS, CLT
Winston Salem State University,
Winston Salem, NC
Abstract:
Purpose: The aims of the study were to differentiate: (1)
physical therapy (PT) students preferred method for learning electrocardiographic (ECG) recognition utilizing standardized patient (SP) and human patient simulation (HPS)
approaches, (2) the impact of HPS or SP on confidence in
interpreting ECG, and 3) the effect of HPS or SP on students ability to make clinical decisions based upon ECG
interpretation. Methods: Three educational methods were
employed to teach ECG recognition to two different years
of novice PT students enrolled in a cardiopulmonary physical therapy class. First, all students had a traditional lecture
on ECG. Following the lecture, two problem-based learning (PBL) approaches were utilized. One approach used a
SP and paper ECG strips, and the second approach utilized
HPS with simulated ECG monitoring.1 Following the two
PBL approaches, a post instructional survey regarding the
learning experiences was conducted. Following instruction, each cohort (n=24, n=29) of PT students was given
a mixed methods survey about their experience. Results:
Survey return rate amongst both cohorts was 77%. Independent sample of individual cohort and paired t-tests of
combined data comparing HPS to SP revealed a strong
preference for HPS (p=0.003 (2008 cohort) and p=0.0001
(2010 cohort)) and combined cohort (p=0.0001). There
were no significant differences in responses between cohorts or preference between the HPS method and the use
of SP and HPS combined. Additionally, 75% of respondents
either strongly agreed or agreed that they felt confident with
their skill in ECG interpretation as presented with HPS or
SP. 90% either strongly agreed or agreed that they understood how the ECG relates to patient treatment. Summative
assessment utilizing HPS revealed that students were competent in their performance in ECG recognition and clinical
decision making related to patient treatment.1 Conclusion:
Data support that HPS was the preferred method to improve
student confidence in ECG recognition and interpretation.
Address correspondence to: Nancy Smith, PT, DPT,
GCS, Winston Salem State University, 601 S. Martin
Luther King Dr., FL Atkins 340, Winston Salem, NC
27110 (smithna@wssu.edu).
36
Key Words: human patient simulation, electrocardiography,

critical care management, educational technology
Introduction
Clinical complexity in the acute care setting is increasing with the advent of early mobility in the intensive care
unit, especially with patients with primary and secondary cardiopulmonary dysfunction.2-7 As early mobility of
patients occurs, educators are challenged with devising
strategies to teach students how to integrate the physical
assessment of the patient with the complex information
provided by physiologic monitoring, while ensuring patient safety.7,8 As noted by Stiller5, the need to determine
safety of treatment through observation of patient response
via hemodynamic and ECG monitoring is paramount prior
to institution of treatment, during treatment, and following
treatment. Safe handling practices, knowledge of potential aberrant responses, and rapid clinician response must
be ensured with treatment in this setting since therapy is
used with the specific intent of challenging the patient, to
provoke, among other things, cardiovascular or respiratory
responses.5 With the aim of teaching students to perform
effectively in the high stakes intensive care environment
where complex integration of information is vital to patient safety, educators are searching for teaching strategies
that accurately simulate this environment and its unique
challenges. New teaching methodologies are required that
strengthen student clinical decision-making in an environment that requires rapid integration of immediate patient
responses and feedback from complex physiological monitoring systems. One such educational method that is currently being developed to address these needs to educate
students on complex acute care issues is human patient
simulation (HPS).
Historically, a problem-based learning (PBL) approach
with the use of role-play and a standardized patient (SP) or a
traditional lecture and laboratory format have been utilized
as established methods for teaching students in physical
therapy education.9 Currently, a new pedagogy is evolving
that employs the use of high fidelity computer-enhanced
mannequins (CEM) with a great degree of physiologic and
physical realism. HPS involves an active or applied learning approach similar to those used with SP, with progres-
sion of scenarios from simple to complex, but employs a

CEM rather than human actor. One benefit of the high
fidelity CEMs over SPs in certain learning activities is the
ability to actively program and visually observe accurate
pathophysiological responses in the CEM in response to a
therapy or intervention. CEMs may also be programmed to
display a range of physiological responses, whereas the human actor cannot actively change their inherent physiology
(ie, initiate an abnormality on ECG at will).
Use of high fidelity CEMs in physical therapy education is in its infancy. A paucity of research exists to support
the validity of HPS in physical therapy education, or in the
preference for use of HPS over other learning methodologies by PT students. However, several studies are available on the utility and preference for integration of HPS
into medicine and nursing education.10-14 One explanation
for this preference for learning utilizing HPS could relate to
the realistic, active and visual learning experience encountered when utilizing HPS, which has been supported in the
literature.12,13 From the authors experience, it would seem
that PT students have similar preferences for HPS as an active mode of learning due to the distinct learning style of
a physical therapy student; a style that is characterized by
active, kinesthetic learning.15
Literature Review
In physical therapy education, there has been an increasing focus on enhancing students abilities to perform
clinical decision-making skills, especially in high acuity environments such as the intensive care unit.16 With the transition to the Doctor of Physical Therapy degree, graduates
are expected to perform with increased clinical proficiency
and evolve into autonomous practitioners with enhanced
diagnostic and evaluative skills that include the management of critically ill patients. In spite of this, the authors
note that in their experience, fewer critical care rotations
are available that allow students to develop autonomous
practice in this setting.17 Clinical instructors at acute care
sites have decreased time to teach the students whom they
are supervising due to increased productivity demands and
decreased reimbursement for services provided. This decrease in clinical mentoring time may reduce the level of
mastery of critical care evaluative and treatment skills that
students are able to attain during their rotation. It is also
noted that patients referred to physical therapy within the
acute care setting often exhibit a higher acuity of illnesses
concurrent with the emphasis on early mobility.2-7 Therefore, physical therapy students must progress in their skills
from novice to entry-level at a faster pace than previously
required in order to function in the present-day clinical environment.
This need for rapid progression of learning and the difficulty of realistically preparing the students for the challenges and complexities of contemporary practice has been
identified by Hayward et al.16 Additionally, in preparation
for students treating patients that are of higher acuity, educators today must emphasize the relevance of their subject
matter. If learning is not contextualized within a relevant
experience, material may be learned on a superficial level

and quickly forgotten.18 For deeper learning to occur, the
pedagogical approach must incorporate: appropriate sequencing of learning, assessment methods focused on
reflective observation and clinical reasoning, interactivity, linking of new and previous knowledge, and discussion with classmates that is either faculty or learner facilitated.18,19 The attainment of deeper learning of the subject
material is evidenced by integration of content into clinical
practice.18 It is with the aim of integration that the use of
HPS or SP as a problem-based learning approach may encourage progression to deeper learning.
In the context of facilitating deeper learning, features
of HPS or SP must be considered. Both HPS and SP can
facilitate deeper learning through their ability to present sequenced, realistic cases, which are contextualized to the
level of the learner. Additionally, these experiences foster
reflection on knowledge gained and performance through
group and individual assessment with debriefing and discussion following the experience. However, a contextual
difference does exist with the use of HPS in its ability to
present accurate physiologic responses. This ability to
demonstrate actual physiological changes may provide
a distinct advantage to using HPS in the development of
deeper learning with physical therapy students. The realism needed for deeper learning may be reflected in scenarios where complex acute care or cardiovascular conditions
need to be modeled, or when interpretation of physiologic
data including ECG monitoring needs to be facilitated.
Both HPS and SP have been shown to enhance student
progression to deeper levels of learning that is paramount
for the mastery of clinical skills. Boissanault et al.9 cited
benefits from SP utilization in fostering deeper learning
with improved ability to perform a screening examination,
improved scores on written exams, and enhancement of
incorporation and application of knowledge in physical
therapy students. Similarly, Shoemaker et al.10 have noted
evidence for creation of deeper learning utilizing HPS in
physical therapy students. In this study, the authors observed a HPS experience related to skills needed in the intensive care unit and cited: the amount of knowledge that
the students gained over traditional teaching methods was
greater; the students demonstrated the ability to critically
think and react to a changing situation; instructors and other students could assess performance; and the experience
resulted in ability to increase self-confidence with the performance of psychomotor and critical thinking tasks vital to
the intensive care setting.10
Due to the benefits cited in the literature to both SP and
HPS, the authors sought to design a simulated experience
related to ECG interpretation. Therefore, the purpose of
this study was to employ both HPS and SP methodologies
followed by survey and summative assessment in order to
(1) assess students preferred method for learning, (2) compare the impact of the approaches on confidence in clinical
decision making, and (3) ascertain comfort and skill with
making clinical decisions about patient treatment related
to the presentation of ECG cases.
37
Methods
Participants and Educational Method
The Winston Salem State University (WSSU) Institutional Review Board approved this project. Two groups of
students enrolled in the required cardiopulmonary course
in subsequent years (2008 and 2010 year-cohorts) participated in the study. In the first year of the study the 2008
year-cohort completed the survey instrument as part of
a curricular assessment, no identifying information was
collected, and retrospective approval was obtained for
use of data for publication. The same survey instrument
was utilized with the 2010 year-cohort of students after
informed consent was obtained. A survey was not collected in 2009, due to the lack of a cardiopulmonary class
offering that year. There was no difference in the survey
instrument, timing of survey distribution, teaching methods, or any other methodology between the two cohorts
including data analysis.
Both year-cohorts were taught methods for interpretation of normal and abnormal ECG rhythms through a traditional lecture. The course curriculum for this lecture remained consistent between years and was taught by the
same instructor. This lecture was followed by a problembased laboratory experience in which a SP and then a CEM
were employed, which also remained consistent between
years. The SP and HPS experiences were outlined according to the principles of Jefferies and Rizzolo.20
To reduce bias towards educational method, a crossover design was utilized with each year-cohort group that
participated in the learning experience. Students in each
year-cohort of the class were initially divided into two
equal groups by random assignment: one that had the HPS
experience first followed by the SP experience, and one
group that had the SP patient experience followed by the
HPS experience.
During the SP experience, the instructor playing the
role of the patient (SP) presented a standardized script containing verbal cues related to symptoms present with the
represented ECG rhythm, utilizing standardized paper ECG
tracings obtained from Wikimedia Commons and the ECG
Learning Center.21,22 From the presentation, students were
asked to make a treatment decision based upon the strip
and symptoms presented. Following the presentation by the
SP, a debriefing session was held to discuss the ECG tracing
interpretation and the appropriateness of treatment decisions the students made during their interactions.
With the HPS experience, an iStan CEM, with physiologic modeling provided by METI HPS 6.0 software,
(Medical Education Technologies Incorporated; 6300 Edgelake Dr; Sarasota, FL 34240) was utilized to generate and
display ECG rhythms on a monitor for interpretation (see
Figure) while symptoms were presented via the voice of
the CEM utilizing the SP actor with an identical script to
the SP experience. Students were again asked to interact
with the simulator and make a treatment decision based
upon the physiologic monitoring, vital signs presented, and
the symptoms the simulator reported. Similarly to the SP
experience, a debriefing session for the HPS was held to
38
discuss the ECG rhythms presented on monitoring and the

appropriateness of treatment decisions made.
Evaluation of Experience
Following the teaching session, students from each cohort were recruited to participate in a survey. The survey
(Table 1) was conducted with a convenience sample via
a mixed method survey design, utilizing a 5-point Likert
scale and qualitative questions that addressed the learning
experience. Qualitative and quantitative data were collected in the aim of assessing students preferred method
for learning ECG interpretation, students perceived confidence in ECG interpretation, and perceived confidence
towards clinical decision making as related to the impact
of ECG findings on patient treatment. Additional qualitative questions were directed towards suggestions for added
learning experiences that addressed ECG recognition, and
changes needed to enhance the learning experience. In
addition to the survey, all students were evaluated with a
summative assessment utilizing a practical exam with HPS
at the end of the course to assess mastery of the material.
Table 1. Survey Questions
5 point Likert Scale Questions
1. The handout for ECG with the simulated patient was more helpful
to my learning than using the simulated rhythms with the human
patient simulator.
2. The simulated rhythms with the human patient simulator were
more helpful to my learning than using the handout with the
simulated patient.
3. I feel that the use of both the simulated patient and human patient
simulator was the most effective way for me to learn
4. Based on my classroom experience, I feel that I have a good
understanding of the ECG and how it relates to patient treatment
5. I feel confident in interpreting ECG from live monitoring as
presented with the simulator.
6. I feel confident in interpreting ECG from rhythm strips as presented
with the simulated patient.
Free Response Questions
Do you have any suggestions for further learning experiences as
related to the ECG?
Is there anything you would change related to the learning of the ECG?
Analysis
Following student completion of the survey instrument,
quantitative analysis was conducted utilizing SPSS statistical software (SPSS 19 for Windows Release 19.0.0. 2011).
Frequencies and descriptive statistics were computed from
the Likert scale data. An independent samples t-test was
selected to compare mean responses to questions about
the use of SP and HPS to determine if a difference existed
between responses provided by each year-cohort. If no difference existed, the cohort-year groups were combined for
further analysis. In addition, an independent samples t-test
was utilized to establish if a significant difference existed in
responses that identified preferred learning method within
a single cohort. Finally, a paired t-test was utilized to compare differences in questions from combined cohort Likert
scale data. To reduce the presence of Type I error, nonpara-
metric tests were run to confirm the results of the parametric tests. Significance was set at p < 0.05 for all analyses.
Further qualitative analysis was conducted utilizing an
inductive, content analysis method.23,24 First, direct transcription was taken from the survey instruments. An initial
coder developed themes from the lines of data from the
most commonly occurring words identified by an electronic word search and categorized each line into a theme
category. The direct transcription was then given to two
separate observers to reduce coder bias and increase coder
reliability. These observers performed independent annotation of the data in a line-by-line analysis to discover the
most common themes or phrases present within the data in
response to each question. Each observer then noted their
individual themes using a constant comparative method
and recorded them. After each independent coder finished
recording their themes, themes and category placement
were compared for inter-coder agreement in theme definition and category placement. The initial coding produced
a theme definition and category placement agreement of
90%. Each coder coded data again until all lines conformed into a category and until 100% agreement was
reached for classification of each line of data into a theme,
which occurred for two separate coding sessions.
Results
The overall return rate on the survey was 77% (n=41,
first cohort 91% (22/24), second cohort 66% (19/29)). Cohort characteristics are noted in Table 2. There were no
statistically significant differences in responses found between years (Table 3). A comparison of individual cohort
(p=0.003 (2008 cohort) and p=0.0001 (2010 cohort)) and
Table 2. Cohort Characteristics
Cohort 1---Class of
2009
Cohort 2Class of
2011
24
29
Gender
30.8% Male
69.2% Female
24.1% Male
75.9% Female
Mean Age
27.7
25.2
Race
African American 34.6%

White 57.7%
Other 27.7%
African American 17.2%

White 79.4%
Other 3.4%
Table 3. Summary of Cohort Differences

QuESTION
Mean sCORE
GroUp 1
MEAn sCORE
Group 2
p Value
Question 1
Question 2
Question 3
Question 4
Question 5
Question 6
2.86
4.14
4.24
4.24
3.86
3.95
3.15
3.64
4.20
4.00
3.63
3.70
0.427
0.089
0.875
0.314
0.273
0.103
significance set at p=.05
combined cohort (p=0.0001) Likert data revealed a strong

preference for HPS over SP. These findings were confirmed
by non-parametric statistics (p=0.001 for individual cohort
and combined cohort). Additionally, when the HPS method
and the use of SP and HPS combined methods were compared utilizing combined cohort data; there was no significant difference in preferred method (p=0.08). Further
analysis showed that, 75% (n=30) either strongly agreed
or agreed that they felt confident with their skill in interpretation of ECG rhythms as presented with HPS or with
rhythm strips, and 90% (n=37) either strongly agreed or
agreed that they had a good understanding of ECG as it
related to patient treatment.1 When a summative practical
exam utilizing HPS was conducted to evaluate knowledge
pertaining to ECG, 100% of students made correct identifications of ECG rhythms and proceeded to make correct
clinical decisions when presented with cases incorporating
ECG monitoring.
From the questions on learning experiences and suggestions for change in experiences, certain themes emerged.
A comprehensive list of themes and supporting statements
is outlined in Table 4. The following themes were found
across both open ended response questions: more case
studies with HPS or SP, more time with simulation, smaller
group size, more practice, immediate debriefing needed
following each rhythm presentation, the simulator is preferred, and the monitor is a good visual tool. On question
one, students also cited that the overall learning experience
was very helpful. With question two, the theme that the
monitored rhythms do not look like the strips emerged.
Discussion
The results of the study show a strong predilection
towards HPS as a preferred method for learning ECG interpretation in physical therapy, which is a novel finding.
This preference is consistent with results from other studies
published in other disciplines.13,14 Similar to other studies,
students cited that: they wanted more time with HPS, more
practice was needed, that the experience was helpful, and
more experiences utilizing simulation were needed to assist them in better application of their knowledge.10
When considering the application of knowledge using HPS compared with a combined approach utilizing SP
and HPS; the students prefer HPS alone. This finding is
interesting to note, since no previous study has compared a
preference for learning between SP and HPS. In considering this preference, one must consider the major difference
in the two techniques; the physiologic realism provided by
the simulator. Since realism is important in the deeper acquisition of context-based instruction,19 it stands to reason
that HPS should be considered as an alternative teaching
method to SP in scenarios where a high degree of physiologic realism is needed to assist in clinical decision-making
processes.
Even though there was strong support and more desire
for the use of HPS to facilitate learning, students stated that
they did like having the paper strips provided with the SP, to
reinforce their learning, and to assist in distinguishing pos-
39
Table 4. Qualitative Themes

Themes from Question One
Supporting Statements
More case studies with HPS or SP
Incorporate more scenarios with moving robot during various ECG.

More case studies related to ECG changes
I liked the combination approach.
More time with simulation
More time with simulated rhythms on human simulators.
Smaller group size
Smaller groups in each group

Continue to use the simulator with small group size.
More interactive with it.
More practice
More on interpretation of heartrate.

Additional ECG labs with the standardized patient would have been beneficial.
The more exposure the better with variety of strips for the same condition.
Immediate debriefing needed following each

rhythm presentation
It would be more beneficial to review each rhythm as it is shown. Visual learners especially benefit
from seeing the rhythm while reviewing correct info about it.
Explain each rhythm and what that rhythm is as we go through it.
Deal with one rhythm at a time and discuss all its aspects.
Talk about the ECG after questioning the patient.
Go through each abnormal rhythm and discuss what is missing, not missing, etc regarding the waves.
Sequence of presentationlook at ECG and discuss each more in depth.
Explain monitor results while going through scenario instead of reviewing results afterward.
Simulator preferred
The simulator was very helpful to learn and understand the ECG, it simulates a real-life experience, it
is better.
Monitor is a good visual tool
The ECG screen is helpful and the robots dont seem to add too much.
The monitor let me see rhythms while they
were happening.
Excellent toolgood visual aid to learning
Overall experience very helpful
Very helpful for learning ECG.

The ECG was very helpful to me.
THEMES FROM QUESTION TWO
SUPPORTING STATEMENTS
More time with simulation
Spend more time with simulator
Monitor is a good visual tool
Liked visually seeing the rhythms on the monitor
Simulator preferred
The standardized patient made my learning a little difficult.

I liked the different ECG presentations of the simulation with verbal cueing from operator.
Learning from the simulator during lab was better for long-term clinical exposure.
I was able to learn more from simulation than I would have without the simulation.
Liked seeing changes in patient response/signs (with simulation).
I dont think the live patient helped me learn anything.
More practice
More practice strips, possibly on blackboard, so we can practice reading ECGs

Hook up a few live patients from the class to see a live model.
Clinical scenario practice in front of human simulator where the ECG changes and we have to
recognize the change.
The strips are a good starting point, but if we could see more strips of the same condition could be
helpful.
Would like to have more class sessions with live monitoring for further practice and review
More online tools to assist us with learning them
Monitored rhythms do not look like the strips
Identification of rhythms may be confusing due to computer program.

Sometimes the (monitored) rhythms do not look like the strips.
Smaller groups
Smaller groups.
Smaller group sizes.
More case studies with HPS or SP
Hook up a few live patients from the class to see a live model.
Clinical scenario practice in front of human simulator where the ECG changes and we have to
recognize the change.
Immediate debriefing needed following each

rhythm presentation
Compare and contrast the rhythms.

It would be better to have visible symptoms on the simulator and discuss each rhythm as it comes.
sible confusing information provided by the monitor. This

theme could be related to the assertions of the problembased learning literature, in which students require some
level of foundational knowledge prior to proceeding to
40
solve a more complex patient case.20 From this finding, it

seems that instructors should spend more time emphasizing early training in a standardized format prior to progression to a more dynamic format, like HPS. This early train-
ing would ensure that students have adequate foundational

knowledge in order to perform integrated learning utilizing
HPS. Training to establish this knowledge could be facilitated with laboratory experiences, lectures, or with partialtask trainers (usually low technology, models of specific
regions of the body) prior to proceeding to higher fidelity
(computer-enhanced) methods of simulation, which tend to
require a high degree of integration. It should also be noted
that the theme emerged that monitored ECG rhythms do not
look like paper ECG tracings. In this light, students should
be didactically prepared to interpret both paper-based and
electronically monitored ECG rhythms, since either paperbased (static) forms of ECG and electronic (dynamic) forms
of ECG are used in clinical practice.
The students identified the value of immediate debriefing and smaller group interaction. While a summative debriefing was performed to foster reflection, the students desired an immediate debriefing following each rhythm presentation to facilitate more immediate clarification. Both
themes are consistent with the problem-based and deep
learning literature.19,25
There are several limitations to the study. While this
sample was one of convenience, the original objective was
to study the effectiveness of implementation of HPS or a
SP into teaching ECG in a cardiopulmonary physical therapy class as a new teaching method. Future studies could
randomize assignment into groups that involved a control
group of traditional lecture, and two intervention groups,
one that utilized SP, and one that utilized HPS in order to
provide a better sampling comparison.
Another limitation of this study was the lack of pre-test
survey that addressed preference towards the different educational methods employed or confidence in ECG interpretation prior to the educational interventions. This pretest survey was not conducted due to the fact that students
did not have prior experience working with a SP, therefore,
they would not be able to address the questions directed
towards the use of a SP appropriately prior to the intervention. In spite of the lack of a pre-test survey, which may
have more conclusively indicated decreased confidence
in ECG interpretation prior to the intervention, there were
multiple comments directed towards the instructor of the
cardiopulmonary class by students participating in the
learning experience. Many students stated limited confidence in interpreting and understanding ECG interpretation
and limited understanding of how to effectively assess and
manage patients with cardiac arrhythmias. Additionally, the
survey did not address a preference for traditional lecture
as a preferred strategy for learning; however, the goal of the
study was to identify the differences between HPS and SP
as learning methodologies for ECG.
The overall effect of the educational methods employed
on confidence and performance on the summative exam
may have resulted from an interference effect between
teaching methods used. Since multiple methods were utilized in teaching the students, reinforcement and repetition
was provided, which limits the ability to conclude which
method had the most effect upon knowledge gained and
confidence. However, such a strong preference existed in

favor of simulation as the learning methodology of choice,
that further studies should address confidence and knowledge gained produced solely from HPS in a pre and posttest manner.
From the questions asked, it is not known if HPS increased safety during clinical rotations. However, anecdotal evidence from interviews during clinical site visits indicated that students that had this learning experience were
more confident than previous students who did not have
the learning experience in their ability to read the electronic monitors and to safely handle patients. In at least two
documented cases, students that had experiences with HPS
exhibited skill in handling high acuity patients. They were
able to respond to emergent situations involving changes
in the ECG and were able to effectively communicate their
clinical decisions to the clinical instructors and physicians.
Further study should be performed, however, to validate
this transfer of training to clinical practice.
Students did not differ significantly in their responses
to the preferred educational methodology across cohorts,
however when cohort responses were compared, Question
2 did approach a statistically significant difference between
the two cohort groups. This could be due to the fact that students may indeed prefer a method of learning in a dynamic,
visual manner that emphasizes realistic practical skills that
informs clinical practice, but may need the reinforcement
of the material by a learning method (paper strips), which
is less dynamic. This finding is consistent with the qualitative responses provided by the cohorts. However, further
longitudinal study is required to see if this result remains
consistent in future cohorts.
Conclusions
Initial data support HPS as the preferred method for
improving physical therapy student confidence in ECG
recognition and interpretation. HPS appears to provide a
pedagogical approach that enhances learning experiences and assists students in applying classroom knowledge
successfully during competency testing. Simulation technologies provide physical therapy educators with an educational approach that can be used to create real world
experiences that were previously impossible with traditional lecture or even SPs in order to facilitate successful application of knowledge for deeper learning of the
material. HPS also provides an opportunity for students
to train in a controlled environment without associated
risk to patients. As a result, students can be exposed to
evaluation and treatment strategies that may prove helpful
in new clinical situations.
Acknowledgements
Special thanks to Dr. Jiangmin Xu for his assistance with
SPSS and statistical measures. Thanks to Dr. Lynn Millar for
her assistance with statistical measures.
This work was funded by a CRAA Title III Special Project
Grant, US Department of Education, Virtual Health Community; with Teresa Conner-Kerr as the principal investigator.
41
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Officer/Committee Chair Directory

President
Ethel M. Frese, PT, DPT, MHS, CCS
St. Louis University
Department of Physical Therapy
3437 Caroline Street
St. Louis, MO 63104
W: 314/977-8535
FAX: 314/977-8513
E-mail: freseem@slu.edu
Vice President
Chris Wells, PT, PhD, CCS, ATC
University of Maryland School of
Medicine
Department of Physical Therapy &
Rehabilitation Services
Suite 215C, 100 Penn Street
Baltimore, MD 21201
W: 410/706-6663
FAX: 410/707-6387
E-mail: cwells@som.umaryland.edu
Secretary
Kristin M. Lefebvre, PT, PhD, CCS
Widener University
Institute for Physical Therapy Education
111 Cottee Hall
One University Place
Chester, PA 19013
W:610/499-1148
E-mail: kmlefebvre@mail.widener.edu
Treasurer & Finance

Ann Fick, PT, DPT, MS, CCS
1042 Parkwatch
Ballwin, MO 63011
W: 314/362-2720
E-mail: afick@maryville.edu
Program
Daniel Malone, MPT, PhD, CCS
3035 S Jericho Ct
Aurora, CO 80013
E-mail: danmal1@msn.com
Legislative & Reimbursement

Ellen Hillegass, PT, EdD, CCS, FAACVPR
220 Lackland Court
Dunwoody, GA 30350
W: 770/846-0350
E-mail: ezhillegass@gmail.com
Public Relations/Booth
Bobby Belarmino, PT, DPT, MA, CCS
School of Public Health
New York Medical College
Valhalla, NY 10595
W: 914/594-4907
FAX: 312/864-9746
E-mail: bobby_belarmino@nymc.edu
Public Relations/Web site
Pamela Bartlo, PT, DPT, CCS
DYouville College
320 Porter Ave.
Buffalo, NY 14201
W: 716/829-8390
FAX: 716/829-7680
E-mail: bartlop@dyc.edu
Membership
Dawn Stackowicz, PT, MS, CCS
4428 N. Dover St. #1
Chicago, IL 60640
W: 312/864-3650
FAX: 312/864-9746
E-mail: dmstacko@core.com
Education
Jennifer Ryan, PT
1208 Woodland Heights Blvd.
Streamwood, IL 60107
Cell: 630/649-8331
Fax: 847/429-3011
E-mail: rushptjen@aol.com
Nominating
Nancy Cielsa, PT, DPT
4048 Stansbury Mill Road
Monkton, MD 21111
H: 443/310-1814
email: nciesla62@google.com
Journal
Anne Swisher, PT, PhD, CCS
Division of Physical Therapy
PO Box 9226
Morgantown, WV 26506
W: 304/293-1319
Fax: 304/293-7105
E-mail: aswisher@hsc.wvu.edu
Research Chair
Christine Wilson, PT, PhD
University of the Pacific
3601 Pacific Ave
Stockton, CA 95211
W: 209/946-2397
FAX: 209/946-2367
E-mail: cwilson@pacific.edu
Specialty Council
Jeffrey Rodrigues, PT, CCS
3502 Canehill Avenue
Long Beach, CA 90808
W: 323/442-5344
E-mail: jeffrod@usc.edu
Fund Raising Committee
Dianne V. Jewell, PT, DPT, PhD, CCS
Virginia Commonwealth University
PO Box 980224
Richmond, VA 23298-0224
W: 804/828-0234
FAX: 804/828-8111
E-mail: dvjewell@vcu.edu
Cardiopulmonary Section Web site

http://cardiopt.org
Cardiopulmonary Physical Therapy Journal Web site
www.cpptjournal.org
Cardiopulmonary
Physical Therapy Journal
2920 East Avenue South, Suite 200
La Crosse, WI 54601

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Official Journal of the Cardiovascular & Pulmonary Section

Cardiopulmonary Physical Therapy Journal

Official Journal of the Cardiovascular & Pulmonary Section

4 Guest Editorial: Physical Therapy in Critical

5 Early Mobilization in the Intensive Care Unit:

Lawrence Cahalin, MA, PT, CCS

26 What are the Barriers to Mobilizing Intensive

Sandra Cassady, PT, PhD, FAACVPR

Advertising & Subscriptions

30 Physical Therapy Management of a Patient

All advertisements which appear in or accompany the Cardio

Vol 23 v No 1 v March 2012

Cardiopulmonary Physical Therapy Journal

Cardiopulmonary Physical Therapy Journal

Susan Scherer, PT, PhD

Vol 23 v No 1 v March 2012

Early Mobilization in the Intensive Care Unit:

Address correspondences to: Joe Adler, PT, DPT, CCS,

Vol 23 v No 1 v March 2012

muscle strength, functional outcomes such as activities of

Cardiopulmonary Physical Therapy Journal

Systematic Review of Randomized Controlled Trials (RCTs)

RCTs with Narrow Confidence Interval

All or None Case Series

Systematic Review Cohort Studies

Cohort Study/Low Quality RCT

Systematic Review of Case-Controlled Studies

Case Series, Poor Cohort Case Controlled

Figure 1. Search algorithm.

Cardiopulmonary Physical Therapy Journal

Vol 23 v No 1 v March 2012

Table 2. Safety and ICU Mobilization

Other notable findings

69 mobilization sessions with 31 patients

3 events (4%) during PT treatments (2

One-group pretest-posttest design

One-group pretest-posttest design

One-group pretest-posttest design

Twice daily PT/ activity

Morris PE. 200825

14 events (<1%) occurred during PT

425 total exercise sessions

Achilles tendon rupture could be considered a

498 PT/ OT sessions:

In patients receiving MV, the primary

Descriptive study/ case series

Vol 23 v No 1 v March 2012

Study provides systems review criteria

(N=104; all patients completed

1449 PT/ activity sessions:

Overall, no adverse medical consequences

116 of 135 patients (80%) of

(N=330; 165 intervention/

Study emphasized the hemodynamic and

Minute ventilation increased

Study highlights the physiologic responses

50 reviewed PT/ OT session with 19

Cardiopulmonary Physical Therapy Journal

Protocol for mobilization(activity

Protocol for mobilization and criteria for

(N = 57 total (27 pre QI; 30

Pre-QI: 210 PT/ OT treatment session

Sitting edge of bed

4 Guest Editorial: Physical Therapy in Critical

5 Early Mobilization in the Intensive Care Unit:

26 What are the Barriers to Mobilizing Intensive

30 Physical Therapy Management of a Patient