PHYSICAL THERAPY

MANAGEMENT
OF PATIENTS IN THE ICU

This protocol is prepared by the

Committee of Physical Therapy protocols,
Office of Physical Therapy Affairs, Ministry
of Health, Kuwait.
With cooperation of
Physical Therapy Department, Kuwait
University. (2003)
Patient Referral:
All patients should be referred by the attending physician
before assessment and treatment. The physical therapist is
responsible to see the patient upon receiving the physical
therapy referral request or according to standard order
(appendix A).

Patient Assessment:
Patient must be assessed within 3 days of referral or
admission (appendix B).

Primary Cardiopulmonary Dysfunction in the ICU:

1.Respiratory failure
2.Heart Failure
3.Cardiac Surgeries
4.Thoracic Surgeries

Secondary Cardiopulmonary Dysfunction in the

ICU:
1. Burns
2. Head Injuries
3. Musculoskeletal Trauma
4. Neuromuscular Dysfunction
5. Acute Spinal Cord Injury
6. Renal Failure
7. Complicated General Surgeries
PHYSICAL THERAPY GOALS FOR PATIENTS IN
THE ICU:

1) Improve / Maintain Normal or Baseline Ventilation and

Oxygenation.
a) Clearance of Airways
b) Improve Chest Expansion
c) Improve Breath Sound
d) Improve Cough Effectiveness
e) Improve Breathing Pattern
2) Improve / Maintain Musculoskeletal System within
Functional Limit.
a) Improve ROM
b) Improve Muscle Strength and Endurance
c) Prevent Joint Deformities and Contractures
3) Improve Circulatory System Function
a) Prevent DVT
b) Prevent Swelling
4) Improve / Maintain Neurological System and Cognitive
Status within Functional Limits.
5) Improve / Maintain Level of Functional Status within
Patient's Tolerance.
 ICU Patient

(A) Intubated (B) Extubated / Non-Intubated

Unconscious Conscious Unconscious Conscious

Points to remember

1. Monitor physiological responses such as heart rate,

blood pressure, respiratory rate and oxygen saturation
at all times. (appendix C)
2. The physical therapist should be aware of effects of
positioning and mobility of the patient on the various
monitoring devices and their readings.
3. The physical therapist should always deal with the
patient as if he/she were conscious and awake even if
the patient appears not to be (talk to him and explain
all procedures he is going through, and do not talk
about his condition within his hearing). This may help
to relax the patient and decrease patient anxiety and
possible subsequent increase in muscle tone.
4. Frequency and intensity of treatment sessions will be
determined by patient condition, but should generally
be at least twice a day.
5. Treatment should be carried out at least 1 1/2 hrs after
feeding time.
6. The physical therapist must be aware of patient's
medication (appendix D), pertinent laboratory test
result (appendix E), patient's management by other
health care team, and patient's / family concerns.
7. The physical therapist should be familiar with all ICU
equipment.
 Pulmonary System

(A) INTUBATED PATIENTS: (endotracheal tube or

tracheostomy)

Unconscious
1. Pre-treat with bronchodilator if the patient presents
with severe bronchospasm (20 min. before treatment).
2. Modified postural drainage positions, usually with the
head of the bed flat unless patient has an increase in
intercranial pressure above 30 mmHg, then the head of the
bed should be elevated to 30 degrees.

If there are no other contraindications (appendix F), then

the following should be done by two therapists:
a) Turn patient to both sides and manually hyperventilate
the patient using the “ambu bag" and hyperoxygenate using
10-15 L O2; if the patient who can't be taken off ventilator,
set the ventilator FIO2 200%
b) Use pulmonary hygiene techniques to mobilize
secretions such as vibration, percussion, rib springs and
shaking.
c) Endotracheal suctioning to clear retained secretions
using sterile techniques.
3. The best position for relaxation, decreased dyspnea
and improved ventilation and oxygenation are with the head
of the bed elevated to 30 degrees and lying on well aerated
lung. The prone lying position is also proven to be
beneficial.

Conscious
Proceed with the same procedures done with the unconscious
patient, and then encourage the following:
1. Independent efforts of inspiration and coughing
2. Coordinate upper extremities mobility with
inspiration and expiration to improve lung expansion
 (B) EXTUBATED OR NON-INTUBATED PATIENTS
Unconscious
Modified postural drainage position, usually with the head of the
bed elevated to 30 degrees, and then performs the following:
1. If no contraindications, then use pulmonary hygiene
techniques to mobilize secretions.
2. Use neurophysiological facilitation of respiration to
facilitate deep breathing, increase lung volume and
increase thoracic expansion. (appendix G)
3. Use tracheal tickle technique to elicit a cough, if not
successful, then use nasopharyngeal suctioning to
clear the retained secretions. It is very important to
hyperoxygenate the patient with 10-15 L O2 prior to
suctioning to avoid complications.
4. If the patient has a tracheostomy, then manually
hyperventilate and hyperoxygenate the patient before
suctioning.
5. Side lying and/or the prone positions are the best positions
to improve oxygenation and ventilation.

Conscious
Modified postural drainage position, usually with head of the bed
elevated to 30 degrees, and then encourages the following:
1. Teach patient effective coughing and huffing to clear
retained secretions.*
2. If cough is non-effective and productive, then
nasopharyngeal suctioning should be performed using
sterile techniques and hyperoxygenating the patient
with 10-15 L O2 to avoid complications
3. If patient has restrictive lung disease, then teach
patient segmental, sustained maximal inspiration,
diaphragmatic breathing exercises and use of incentive
spirometer 10 X hour to increase lung volume.*
4. Teach patients with COPD pursed lip breathing
exercises to decrease dyspnea and prolong exhalation
phase.*
* could be done in upright position as patient tolerates
 Musculoskeletal System

Unconscious
To avoid contractures and deformities, concentrate on the
following:
1. Passive ROM of upper and lower extremities
including prolonged stretching.
2. Use of splints (by keeping most joints in the neutral
or functional position). Inhibitive casting or patient’s
shoes can also be used.
3. Proper positioning for all joints of the body.

Conscious
Proceed with the same procedures done with the unconscious
patient, in addition to the following:
1. Active, active assistive ROM of upper and lower
extremities.
2. Strengthening exercises of upper and lower extremities.

Circulatory System

Unconscious
To prevent DVT and swelling, concentrate on the following:
PROM, elastic crepe bandage, compression unit, and limb
elevation.

Conscious
Proceed with the same procedures done with the unconscious
patient in addition to the following:
1. Use ice pack to decrease swelling.
2. Encourage active exercise of all extremities and trunk.
 Neurological System, Cognitive and Functional
Status

Unconscious

(Glasgow coma scale below 9 + Rancho los Amigos

cognitive scale below level 4) (appendix H)
1. Work with the patient to reach the next higher cognitive
level and increase level of arousal and response using
different familiar auditory, visual, tactile, olfactory and
proprioceptive stimuli. (For this purpose, ask the family
to identify what patient likes and dislikes). Only one
sensory system should be stimulated at a time, with
intervals to prevent patient’s accommodation to the
stimulus. Also, ensure giving the patient adequate time
to respond.
2. The carryover of a structured program of sensory
stimulation throughout the day requires the
involvement of the family as well as all members of the
medical team. Careful documentation should be kept
on any response observed and type of stimuli used as
well as their frequency, duration and intensity.
3. The patient must be oriented to place, person and time
by health care team and family members.
4. To decrease limb spasticity keep hips flexed and
abducted, or position patient in side lying. For
decerebrate posture, use asymmetric tonic reflex on
affected side to decrease upper limb extended tone.
Symmetric neck reflex is used for decorticate posture
to decrease flexor tone in the upper limbs and extensor
tone in the lower limbs. Using ice pack can also
decrease limb spasticity.
5. Activities in the upright and bed mobility can be used to
improve muscles tone and facilitate active movement
which will provide vestibular and tactile stimulation and
improve lung function.
6. Patient should be in the upright position as soon as
possible (by gradually raising the head, using the tilt
table or transferring patient to the chair) to prevent
osteoporosis, to improve lung function, to increase the
environmental interaction, and to provide stress on the
cardiovascular system.
7. Work on head and trunk control and use weight-
bearing activities for the upper limbs while patient is at
the edge of the bed to promote equilibrium reactions
and to improve muscles tone. The therapist can move
the patient passively in this position to give him feeling
of weight shifting. When the patient is sitting at the
edge of the bed, ensure that his feet are well
supported to provide stimulation and feedback and to
encourage some weight bearing through the lower
limbs.

Conscious (or Patient regaining consciousness)

1. Patient will need to be reoriented several times during
each treatment session as the state of partial
consciousness may trigger confusion, disorientation
and consequently aggressive behavior. To prevent this
from occurring, use large and prominent bulletin
boards, calendars and clocks, and keep the routine
and sequence of activities known to the patient.
2. Treatment activities should be kept simple and
automatic using simple explanations that allow the
patient to succeed with most tasks.
3. Work according to the patient’s attention span during
all sessions. Each session will concentrate on
automatic righting, equilibrium and reinforce normal
movement patterns which can easily be achieved by
the use of a task-oriented approach. Rest periods must
be provided frequently for the patient during the
treatment session.
4. The use of a task-oriented approach will encourage the
patient to perform his own, active ROM of upper and
 lower extremities and consequently, promote motor
control. If indicated use visual demonstration, visual
feedback, tactile and proprioceptive methods to
improve patient's sensory awareness.
5. Increase patient’s functional activity by encouraging
independent transfers in and out of bed, standing,
marching in place and ambulation.
6. The therapist can use active assisted exercise for
patient with functional limitation (severe to moderate
physical impairment) to stimulate active participation.
 Appendices

• Appendix A

Standard order for main ICU

Physiotherapy Referral Form

• Appendix B

Cardiopulmonary Assessment

• Appendix C

Vital Signs
• Appendix D
Drugs used in the ICU

Neurological System

Cardiovascular System

Respiratory System

Renal System

• Appendix E
Pertinent Laboratory Test Results

Arterial and Venous Blood Gases

Pressures

Admission Profile: Biochemistry and Liver
Profile

Hematology CBC

Sputum Culture

Serum Chemistry Values in Acute Myocardial
Infarction

• Appendix F

Contraindications and Precautions for Postural Drainage

Contraindications and Precautions for Vibration,
Percussion, Shaking and Rib Spring

• Appendix G

Neurophysiological Facilitation for the Chest

• Appendix H

Glasgow Coma Scale

Rancho Los Amigos Cognitive Scale
 Physical Therapy Protocol Committee:-

• Ali Al-Mohanna (Al-Farwaniya Hospital)

• Khadijah Al-Ramezi
• Dr.Sabriyah Al-Mazeedi
• Saud Mohammad
• Tamadur Al-Said
• Noura Al-Jwear
• Maali Al-Ajmi
• Mariam Al-Otabi
(Ibn Sina Hospital)
(Kuwait University)
(Al-Amiri Hospital)
(Allergy Center)
(Al-Farwaniya Hospital)
(Maternity Hospital)
(Mubarak Hospital)

This Protocol is a guideline only and may vary from

patient to patient