1. ICU Liberation: How Physical Therapy Is Part of Reducing the Harms of Critical Illness
Presented by Heidi Engel, PT, DPT
UCSF Department of Rehabilitative Services
University of California San Francisco Medical Center
February 2015

2. Disclosures
Academic work in the ICU setting for Heidi Engel, PT, DPT is funded by a grant from the Gordon and Betty Moore Foundation

3. Objectives
Explain the importance of providing early physical rehabilitation to patients in the ICU
Reinforce and define the role of Physical Therapists in providing care to critically ill patients as part of an inter-professional collaborative care ICU team
Define the barriers to ICU early physical rehabilitation and suggest solutions to overcome those barriers
Cite patient case studies that illustrate Physical Therapy clinical decision making in the ICU setting

4. Course Outline
Complex ICU case presentation emphasizing unique psycho-social aspects of ICU early physical rehabilitation
Consequential harms to patients as a result of an ICU stay- weakness, immobility, delirium, long term functional and cognitive impairments
Recommendations from Society of Critical Care Medicine outlined
Example ICU early rehabilitation programs
Assessing how we are doing
Barriers- looking at 3 issues at the bedside keeping patients immobile- immobility is safety, timing and priorities, staffing and equipment
ICU case presentation illustrating unique role of Physical Therapists

5. Society of Critical Care Medicine ICU Liberation- Free Your Patients from Potential Harms
ICU Acquired Weakness (ICUAW) Immobility Delirium Long term cognitive impairments Functional decline Inability to return to previous employment or activities of daily living

6. Why Early ICU Patient Mobility?
Diaphragm muscle thinning and atrophy begins within 18 to 48 hours after intubation
Levine, S., T. Nguyen, et al. (2008).
Grosu HB, Lee YI, Lee J, Eden E, Eikermann M, Rose KM: (2012).
Rectus Femoris protein breakdown begins within 24 hours of ICU admission, cross sectional area declining rapidly during first week
Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Padhke R, Dew T, Sidhu PS et al (2013).

7. ICU Acquired Weakness
Change in architecture of muscle fibers within 18 to 69 hours
Loss of bone mineral density, bone adapts to the load placed on it, ALI patients have 19% greater risk of fracturing, 10 day study with average patient age of 55
Frailty: Fried Frailty Index, hallmark is neuromuscular weakness, every 1 pt increase equal to 3X increased risk of 6 month mortality, 82% of older Icu survivors qualify as frail
Kress JP, Hall JB (2014).
Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Padhke R, Dew T, Sidhu PS et al (2013)
Baldwin MR, Reid MC, Westlake AA, Rowe JW, Granieri EC, Wunsch H, Dam TT, Rabinowitz D, Goldstein NE, Maurer MS et al: (2014).

8. Why Early ICU Patient Mobility?
The duration of bed rest during critical illness was consistently associated with weakness throughout 24-month follow-up.
Fan E, Dowdy DW, Colantuoni E, Mendez-Tellez PA, Sevransky JE, Shanholtz C, Himmelfarb CR, Desai SV, Ciesla N, Herridge MS et al (2013).
Based on available evidence, early exercise/PT seems to be the only treatment yet shown to improve long-term physical function of ICU survivors.
Calvo-Ayala E, Khan BA, Farber MO, Ely EW, Boustani MA (2013).

9. Interpretation of PAD Guidelines
Society of Critical Care Medicine Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium (PAD) Guidelines Barr J, et al., Critical Care Medicine 2013
Interpretation of PAD Guidelines
Quality of evidence: statements and recommendations
High (A)
Moderate (B)
Low/Very Low (C)
Strength of recommendations: recommendations only
Either strong (1) , weak (2), or none (0)
Either in favor of an intervention (+) or against an intervention (-)

10. Outcomes Associated with Delirium in ICU Patients
Delirium is associated with increased mortality in adult ICU patients (A).
Delirium is associated with prolonged ICU and hospital lengths of stay in adult ICU patients (A).
Delirium is associated with the development of post-ICU cognitive impairment in adult ICU patients (B).

11. Depth of Sedation in ICU Patients
Light levels of sedation associated with improved clinical outcomes (e.g., shorter duration of mechanical ventilation and a shorter ICU length of stay) (B).
Light levels increase physiologic stress response, but is not associated with an increased incidence of myocardial ischemia (B).
The association between depth of sedation and psychological stress in these patients remains unclear (C).

12. Depth of Sedation in ICU Patients (cont.)
Recommend that sedative medications be titrated to maintain a light rather than a deep level of sedation, unless contraindicated (+1B).
Recommend routinely using either daily sedation interruption or targeting light level of sedation in MV patients (+1B).

13. Delirium Prevention
We recommend performing early mobilization of adult ICU patients whenever feasible to reduce the incidence and duration of delirium (+1B)
Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM et al (2013)
Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D et al: (2009)
Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Palmer JB, Brower RG, Fan E (2010).

14. Functional Decline Related to ICU Stay
Long Term Problem
3.3 year median follow up after d/c from trauma ICU 100 patients
70% consider themselves less active than pre-injury
49% returned to work.
Livingston DH, Tripp T, Biggs C, Lavery RF (2009).
More than 6 years after a surgical ICU admission, HRQOL is largely reduced. Many patients still have a variety of health problems, including decreased cognitive functioning.
Timmers, T. K., M. H. Verhofstad, et al. (2011).

15. ICU Liberation Project of SCCM
&
SYMPTOMS 
PAD GUIDELINES
MONITORING
TOOLS
CARE 
ABCDEF BUNDLE
PAIN
BPS
NPS
CPOT
Assess / Treat Pain
Awakening Trials - SATs
Breathing Trials SBTs
Coordination of Care
Choice of Sedatives
Delirium Reduction
Diseases, Drug Removal, Environment
e.g., sleep, noise, eye glasses, hearing aids
Early mobility and Exercise
Family - Communication and Involvement
AGITATION
RASS
SAS 
DELIRIUM
CAM-ICU
ICDSC

16. Neurocognitive and Functional Benefits to ICU Patients
Schweickert WD, Pohlman MC, Pohlman AS, et al. (2009).
RCT- 104 patients on mechanical ventilation
intervention group- PT median of 1.5 days intubation
control group PT median of 7.4 days
Intervention group-
less days of delirium and MV
59% return to independent function at hospital discharge 35% in control group .

17. Role Models- LDS Medical Center
LDS Medical Center Mobility Protocol
Walk 200’ prior to extubation
Walk 400’ prior to ICU discharge
When patients appear not to have strength to do both reconditioning and weaning, support reconditioning first, then weaning.
Support work of breathing during physical activity.
Advance activity aggressively NOT progressively, patients will do the most that they can do at any given time.

18. UCSF ICU Early Mobilization Started March 1st, 2010 9 ICU
Physical Therapy coverage 8 hours/day
5 or 6 days/week in 9 ICU
Objective- referrals for physical therapy within 48 hours of patient admission to the ICU
Objective- most ICU patients ambulating during their ICU stay
Goals-
patients wean ventilators faster
sleep better/experience less delirium
leave the ICU sooner

19. Staffing and Equipment
UCSF- one full time PT added
No additional RN or RT staff
ICU platform walker, ear plugs, eye masks, seating cushions
PTs mobilize patients to higher level than RNs
Garzon-Serrano, J., C. Ryan, et al. (2011).

20. UCSF Exclusion Guidelines
Patients with immediate plans to transfer to outside hospital
Patients who require significant doses of vasopressors for hemodynamic stability (maintain MAP> 60)
Mechanically ventilated patients who require FiO2 .8 and/or PEEP >12, or have acutely worsening respiratory failure
Patients maintained on neuromuscular paralytics
Patients in an acute neurological event (CVA,SAH, ICH) with re-assessment for mobility every 24 hours
Patients with RASS less than -3 or greater than +2
Patients with unstable spine or extremity fractures
Patients with a grave prognosis- transferring to comfort care
Patients with open abdomen, at risk for dehiscence

21. How Are We Doing? Point Prevalence Studies:
Nydahl P, Ruhl AP, Bartoszek G, Dubb R, Filipovic S, Flohr HJ, Kaltwasser A, Mende H, Rothaug O, Schuchhardt D et al: (2014)
In this 1-day point-prevalence study conducted across Germany
only 24% of all mechanically ventilated patients OOB
only 8% of patients with an endotracheal tube were mobilized out of bed as part of routine care.

22. How Are We Doing? Point Prevalence Studies:
Berney SC, Harrold M, Webb SA, Seppelt I, Patman S, Thomas PJ, Denehy L (2013).
45% were mechanically ventilated
140 patients (28%) completed an in-bed exercise regimen
93 (19%) sat over the side of the bed
182 (37%) sat out of bed
124 (25%) stood
89 (18%) walked
Predefined adverse events occurred on 24 occasions (5%)
No patient requiring mechanical ventilation sat out of bed or walked

23. How Are We Doing? Point Prevalence Studies:
Terri Hough University of Washington Medical Center, Presenting at The 7th International Physical Medicine and Rehabilitation of Critically Ill Patients Meeting 5/17/2014, Across the US:
64% of ICU patients experienced any activity
50% of those were bed level activity
20% of those were transfers to a chair
10% of those were walking
Profoundly variable practice patterns

24. How Are We Doing? ICU Early Mobility Protocols
Critical Care Medicine February 2014
Survey of 69 ICUs across the United States looking at structure, process, and outcomes
97-99% have protocols for ventilator management, infection control, nutrition, and VTEs
36% have an Early Mobility protocol, all requiring a MD Order to initiate (A Process Barrier)
Checkley W, Martin GS, Brown SM, Chang SY, Dabbagh O, Fremont RD, Girard TD, Rice TW, Howell MD, Johnson SB et al :(2014).

25. Resulting Harm to Patients
“ Tracheostomy, female gender, higher Charlson Comorbidity Index and lack of early ICU mobility were associated with readmissions or death during the first year.
Although the mechanisms of increased hospital readmission are unclear, these findings may provide further support for early ICU mobility for patients with acute respiratory failure.”
Morris PE, Griffin L, Berry M, Thompson C, Hite RD, Winkelman C, Hopkins RO, Ross A, Dixon L, Leach S et al (2011).

26. How are we doing in the hospital overall?
32 % of older patients not engaged by an RN in ANY mobility event during an 8-hour period.
Mean duration of ambulation was less than 2 minutes.
Mean age 74.6, 55.3% using an assistive device, 95.6% had an MD order for out of bed activity, none met criteria for dependent patient.
Average length of stay 6.7 days
Doherty-King B, Yoon JY, Pecanac K, Brown R, Mahoney J (2014)

27. After Patients Leave the ICU?
Of the 72 patients who participated in the study
65 had either a physical therapy consultation or a request for nursing assistance with ambulation at ward transfer (90%)
Activity level decreased in 40 participants (55%) on the first day
Of the 61 participants who ambulated 100 ft or more on the last RICU day (85%)
14 did not ambulate, 22 ambulated less than 100 ft (59%)
25 ambulated 100 ft or more on the first ward day (41%)
Hopkins RO, Miller RR, 3rd, Rodriguez L, Spuhler V, Thomsen GE: (2012).

28. Mobility is Medicine Improves blood sugar homeostasis
Health Benefits of Physical Activity
Improves blood sugar homeostasis
Enhances cardiovascular function
Enhances endothelial function
Decreases chronic inflammation
Regulates hormone levels
Preserves musculoskeletal and neuromuscular integrity
Decreases depression and improves cognition
Warburton DE, Nicol CW, Bredin SS. (2006).

29. Barriers to Implementation
Nervous or skeptical clinicians
Minimal resources allocated
Awkward equipment
PT referrals still too late
Unclear protocol
Mobility prior to extubation is difficult concept
Rotating and changing personnel
Variations in sedation practices
New hospital and discharge course predictions required for ICU and floor personnel
Pawlik AJ, Kress JP. (2012).

30. 3 Common Issues Keeping an ICU Patient Immobile
Are we patient centered or screen centered in our practices? Immobility is Safety Timing and Priorities Staffing and Equipment

31. Issue # 1. Immobility is Safety: The patient is too sick, or too big
TRUE:
New onset sepsis or respiratory distress (think of hours NOT days)
Unstable bleeding or surgical site
Terminal disease (comfort care measures),
Comatose
Acute unstable cardiovascular event

32. Solution # 1. Awake and Mobile is Safer
Collaborate with RN,RT, MD Use Clinical judgment Every diagnosis in context Delay increases risk later

33. Essential Information to Share
Medical History- impact of the chronic, plus current level of acuity
Physiologic Reserve
Motivation and Goals- what are patient expectations?
Cognition- anxiety, delirium, co-morbidity
Pain
Sedation- why is this patient being sedated?
Extubation- how is the patient tolerating breathing trials?
Procedures- dialysis, IR, CT scan?

34. Context Is it a beautiful sunny day after so much rain, or are we in the middle of a drought?

35. Solution # 1. Awake and Mobile is Safer
The patient is too sick, or too big
FALSE: The patient has a DVT (reference the American College of Chest Physicians 2012 guidelines: people with acute DVT do not need a period of bed rest)
FALSE: The obese patient was admitted able to walk at home (think of how crucial prevention can be)
FALSE: The patient is on ARDS Net Protocol
FALSE: The patient is a new admit to the ICU

36. Consider the Patient Physiologic Reserve, their Personal Fitness Account
Did this patient walk into your hospital? What has the patient done in the past 2days, 2 weeks, 2 months, 2 years? What are your assumptions?

37. Issue # 1. Immobility is Safety Excuse: The patient is too lethargic, tired? RASS -2 to -4 Hypoactive delirious Target RASS vs Actual RASS Goal targeted sedation?

38. Richmond Agitation Sedation Scale (RASS) icudelirium.org
+4 Combative Overtly combative, violent, immediate danger to staff
+3 Very agitated Pulls or removes tube(s) or catheter(s); aggressive
+2 Agitated Frequent non-purposeful movement, fights ventilator
+1 Restless Anxious but movements not aggressive vigorous
0 Alert and calm
-1 Drowsy Not fully alert, but has sustained awakening
(eye-opening/eye contact) to voice (>10 seconds)
-2 Light sedation Briefly awakens with eye contact to voice (<10 seconds)
-3 Moderate sedation Movement or eye opening to voice (but no eye contact)
-4 Deep sedation No response to voice, but movement or eye opening
to physical stimulation
-5 Unarousable No response to voice or physical stimulation

39. Solution to when the patient is too lethargic
Collaborate with RN,RT, MD Use Clinical judgment Every level of delirium in context Consider the environment, disease, medications Delirium is treated with mobility
Target RASS Zero

40. ICU Sleep Promotion Programs
Consider the Noise level
Lighting
Night time routines
Circadian Rhythms
Kamdar BB, King LM, Collop NA, Sakamuri S, Colantuoni E, Neufeld KJ, Bienvenu OJ, Rowden AM, Touradji P, Brower RG et al (2013).
Kamdar BB, Needham DM, Collop NA: (2012).

41. Solution# 2. Mobility will re-orient and decrease lethargy The patient may respond well to being up and communicating Include the family in patient care activities

42. Solution # 3. The patient is too agitated, awake and re-oriented helps
Society of Critical Care Medicine Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium
“We recommend performing early mobilization of adult ICU patients whenever feasible to reduce the incidence and duration of delirium” (+1B)
Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM et al (2013).

43. What About All Those Critical Lines?
Patient lines and drains can be accommodated
Including Femoral Lines
Mechanical ventilation and CVVH lines
Damluji, A., et al. (2013).
Winkelman, C. (2011).

44. Issue #2 Timing and Priorities: The patient is leaving
The patient is going for: A procedure A CT scan Transferring to the floor Will be extubated soon

45. Solution: Mobility Is High Priority Activity Trumps Extubation:
A pre- and post-activity rest period with assist-control ventilation for 30 min was employed as needed to support early activity.
If the patient was intubated and able to participate in activity, the FIO2 was increased by 0.2 before initiation of activity. We deferred ventilator weaning in support of activity, as necessary.
Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, Veale K, Rodriquez L, Hopkins RO: (2007).

46. Issue #2Timing and Priorities: The patient needs a nap
Had a bad night
Feels tired
Didn’t sleep last night
Wants to sleep now to make up for it
Kamdar BB, Needham DM, Collop NA (2012).

47. Solution for Timing and Priorities: The Patient Needs a Short Rest
Schedule a time Create a sleep hygiene program in your ICU Address night staff as well as day Set circadian rhythms

48. Issue #3 Staffing/Equipment : No one is available to manage the lines
No portable ventilator No high back chairs No minimal lift equipment No full time PT Where are family members?

49. Solution for Staffing/Equipment: Overcome the Barriers
Establish the program for your local culture
Begin with the easier smaller success stories
Collect data to evaluate and re-evaluate
Make a Financial case
Lord RK, Mayhew CR, Korupolu R, Mantheiy EC, Friedman MA, Palmer JB, Needham DM: ICU early physical rehabilitation programs: financial modeling of cost savings. Crit Care Med 2013, 41(3):
Kress JP: Sedation and mobility: changing the paradigm. Crit Care Clin 2013, 29(1):67-75.

50. Solution: Consider Patients Expectations and Patient Centered Goals
Returning to life as they knew it
Not a new life of disability or perpetual patient
Include Family in patient care activities
Misak C. (2005).
Muller M, Strobl R, Grill E. (20110>

51. Solution to Staffing Equipment : the PT is not here
Seeing is believing
Create learning opportunities
Build the case for a full time dedicated ICU PT
Collect Data!
Plan ahead and coordinate care
Lord RK, Mayhew CR, Korupolu R, Mantheiy EC, Friedman MA, Palmer JB, Needham DM (2013).

52. Sitting on the Edge of the Bed
Trunk control
Vestibular training
Joint compression
Joint/muscle stretching
Lung expansion
Airway clearance
Aerobic exercise? (Yes!)
GI motility
Orientation, mental status
Endurance

53. Walking in the ICU

54. Allowing our patients to communicate their needs Assessing and treating pain first Preventing PTSD Journaling the experience

55. In Summary
Critical illness is catabolic and depleting, rapidly and potentially lasting for years
A prolonged ICU stay can cause delirium and cognitive changes for most patients
Mobility (mostly walking) combined with minimal or no sedation started at the beginning of an ICU stay is protective and preventative
Approach the task with structured QI project, collaboration, barrier identification

56. References
Levine, S., T. Nguyen, et al. (2008). "Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans." N Engl J Med 358 (13):
Grosu HB, Lee YI, Lee J, Eden E, Eikermann M, Rose KM: Diaphragm muscle thinning in patients who are mechanically ventilated. Chest 2012, 142(6):
Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Padhke R, Dew T, Sidhu PS et al: Acute Skeletal Muscle Wasting in Critical Illness. Jama 2013.
Kress JP, Hall JB: ICU-acquired weakness and recovery from critical illness. N Engl J Med 2014, 370(17):
Baldwin MR, Reid MC, Westlake AA, Rowe JW, Granieri EC, Wunsch H, Dam TT, Rabinowitz D, Goldstein NE, Maurer MS et al: The feasibility of measuring frailty to predict disability and mortality in older medical intensive care unit survivors. J Crit Care 2014, 29(3):

57. References
Schefold, J. C., J. Bierbrauer, et al. (2010). "Intensive care unit-acquired weakness (ICUAW) and muscle wasting in critically ill patients with severe sepsis and septic shock." J Cachex Sarcopenia Muscle 1 (2):
Fan E, Dowdy DW, Colantuoni E, Mendez-Tellez PA, Sevransky JE, Shanholtz C, Himmelfarb CR, Desai SV, Ciesla N, Herridge MS et al: Physical Complications in Acute Lung Injury Survivors: A 2-Year Longitudinal Prospective Study. Crit Care Med 2013.
Calvo-Ayala E, Khan BA, Farber MO, Ely EW, Boustani MA: Interventions to improve the physical function of ICU survivors: a systematic review. Chest 2013, 144(5):
Gunther ML, Morandi A, Krauskopf E, Pandharipande P, Girard TD, Jackson JC, Thompson J, Shintani AK, Geevarghese S, Miller RR, 3rd et al: The association between brain volumes, delirium duration, and cognitive outcomes in intensive care unit survivors: the VISIONS cohort magnetic resonance imaging study*. Crit Care Med 2012, 40(7):

58. References
Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM et al: Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013, 41(1):
Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D et al: Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009, 373(9678):
Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Palmer JB, Brower RG, Fan E: Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil 2010, 91(4):
Livingston DH, Tripp T, Biggs C, Lavery RF. A fate worse than death? Long-term outcome of trauma patients admitted to the surgical intensive care unit. J Trauma. Aug 2009; 67(2): ; discussion
Timmers, T. K., M. H. Verhofstad, et al. (2011). "Long-term quality of life after surgical intensive care admission." Arch Surg 146 (4):

59. References
Sacanella E, Perez-Castejon JM, Nicolas JM, Masanes F, Navarro M, Castro P, et al. Functional status and quality of life 12 months after discharge from a medical ICU in healthy elderly patients: a prospective observational study. Crit Care. 2011;15 (2): R105
Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. May
Garzon-Serrano, J., C. Ryan, et al. (2011). "Early Mobilization in Critically Ill Patients: Patients' Mobilization Level Depends on Health Care Provider's Profession." PM R 3(4):
Nydahl P, Ruhl AP, Bartoszek G, Dubb R, Filipovic S, Flohr HJ, Kaltwasser A, Mende H, Rothaug O, Schuchhardt D et al: Early mobilization of mechanically ventilated patients: a 1-day point-prevalence study in Germany*. Crit Care Med 2014, 42(5):
Berney SC, Harrold M, Webb SA, Seppelt I, Patman S, Thomas PJ, Denehy L: Intensive care unit mobility practices in Australia and New Zealand: a point prevalence study. Crit Care Resusc 2013, 15(4):

60. References
Checkley W, Martin GS, Brown SM, Chang SY, Dabbagh O, Fremont RD, Girard TD, Rice TW, Howell MD, Johnson SB et al: Structure, process, and annual ICU mortality across 69 centers: United States critical illness and injury trials group critical illness outcomes study*. Crit Care Med 2014, 42(2):
Morris PE, Griffin L, Berry M, Thompson C, Hite RD, Winkelman C, Hopkins RO, Ross A, Dixon L, Leach S et al: Receiving early mobility during an intensive care unit admission is a predictor of improved outcomes in acute respiratory failure. Am J Med Sci 2011, 341(5):
Doherty-King B, Yoon JY, Pecanac K, Brown R, Mahoney J: Frequency and duration of nursing care related to older patient mobility. Journal of nursing scholarship : an official publication of Sigma Theta Tau International Honor Society of Nursing / Sigma Theta Tau 2014, 46(1):20-27.
Hopkins RO, Miller RR, 3rd, Rodriguez L, Spuhler V, Thomsen GE: Physical therapy on the wards after early physical activity and mobility in the intensive care unit. Physical therapy 2012, 92(12):
Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. Cmaj. Mar ;174(6):

61. References
Pawlik AJ, Kress JP. Issues Affecting the Delivery of Physical Therapy Services for Individuals With Critical Illness. Phys Ther
Kamdar BB, King LM, Collop NA, Sakamuri S, Colantuoni E, Neufeld KJ, Bienvenu OJ, Rowden AM, Touradji P, Brower RG et al: The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU. Crit Care Med 2013, 41(3):
Kamdar BB, Needham DM, Collop NA: Sleep deprivation in critical illness: its role in physical and psychological recovery. Journal of intensive care medicine 2012, 27(2):
Damluji, A., et al. (2013). "Safety and feasibility of femoral catheters during physical rehabilitation in the intensive care unit." J Crit Care.
Winkelman, C. (2011). "Ambulating with pulmonary artery or femoral catheters in place." Crit Care Nurse 31(5):

62. References
Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, Veale K, Rodriquez L, Hopkins RO: Early activity is feasible and safe in respiratory failure patients. Crit Care Med 2007, 35(1):
Lord RK, Mayhew CR, Korupolu R, Mantheiy EC, Friedman MA, Palmer JB, Needham DM: ICU early physical rehabilitation programs: financial modeling of cost savings. Crit Care Med 2013, 41(3):
Kress JP: Sedation and mobility: changing the paradigm. Crit Care Clin 2013, 29(1):67-75.
Misak C: ICU psychosis and patient autonomy: some thoughts from the inside. The Journal of medicine and philosophy 2005, 30(4):
Muller M, Strobl R, Grill E: Goals of patients with rehabilitation needs in acute hospitals: goal achivement is an indicator for improved functioning. J Rehabil Med 2011, 43(2):
Engel HJ, Needham DM, Morris PE, Gropper MA: ICU early mobilization: from recommendation to implementation at three medical centers. Crit Care Med 2013, 41(9 Suppl 1):S69-80.