Rethinking rehabilitation in the ICU: What the recent evidence tells us

A recent review in Intensive Care Medicine sets out the current standard of care for rehabilitation across the full trajectory of critical illness, from ICU admission through to community recovery, with clear implications for physiotherapists working in and around critical care settings.

Critically ill patients are now older, more comorbid and spending longer in the ICU than ever before. Muscle wasting can begin within hours of admission, and more than one million people globally develop ICU-acquired weakness each year. For physiotherapists, this is not an abstract statistic, it is the clinical reality of the patients arriving on your caseload, and a growing body of evidence is shaping what high-quality rehabilitation for this group should look like.

This recent research has synthesised the latest randomised controlled trials, meta-analyses and clinical practice guidelines on ICU rehabilitation. Their key message is unambiguous: rehabilitation is now a core component of modern intensive care, not an optional add-on, and physiotherapists are central to its delivery. Over 100 systematic reviews have now evaluated physical rehabilitation in the ICU, and the evidence is consistent that early mobilisation is safe, with very low adverse-event rates, and it improves muscle strength, physical function and reduces time on mechanical ventilation and length of hospital stay.

The review is particularly useful in detailing what physical rehabilitation in the ICU actually looks like in practice. The three most evaluated in-bed approaches are functional rehabilitation (bridging, sitting at the edge of the bed, standing and walking), cycle ergometry and neuromuscular electrical stimulation (NMES). Each has a different evidence base and practical profile. Functional activities are the most common and flexible but have the most variably reported parameters in the literature. Cycle ergometry is well documented and allows passive-to-active progression based on patient capacity, though a recent major trial (the CYCLE study) found that adding it to usual physiotherapy did not improve function at three days post-ICU discharge compared to physiotherapy alone. NMES is passive and well tolerated, but attaining adequate muscle contraction can be inconsistent, and its benefit is most likely to be limited in patients with lower limb oedema, established nerve injury or vasopressor use.

Beyond the physical, the review gives considerable weight to cognitive and psychological rehabilitation. Delirium is the most common form of acute brain dysfunction in the ICU and is strongly associated with long-term cognitive impairment. Physiotherapists play a direct role here: early mobilisation has been shown to reduce both the incidence and duration of delirium, and including simple reorientation activities, sitting upright and promoting daytime wakefulness within your sessions contributes meaningfully to cognitive outcomes. The review also highlights the importance of ensuring patients have access to their glasses and hearing aids, as sensory deprivation significantly worsens delirium risk and limits engagement in rehabilitation.

The review is frank about implementation. Point prevalence studies from Australia, the UK, Germany, the USA and Brazil all show that rehabilitation is still inconsistently delivered in practice, despite international guidelines recommending it. Barriers include heavy sedation practices, concerns about safety, limited staffing and variable team culture. The authors call for protocolised early mobilisation pathways, systematic goal-setting during daily rounds and coordinated handover of rehabilitation across transitions from ICU to ward to community, all areas where physiotherapists are well placed to advocate and lead.

One emerging priority is post-discharge care. The review highlights that most ICU survivors currently face a significant gap in specialist support after leaving hospital, with post-ICU clinics typically not occurring until 8 to 12 weeks after discharge. Digital recovery pathways with a dedicated recovery coordinator are flagged as a promising model, and combined nutrition and rehabilitation trials are underway.

The Physiopedia pages on ICU-Acquired Weakness and related critical care topics are being updated to reflect this latest evidence, ensuring the content your colleagues rely on stays current. If you come across new research that you think should be incorporated into a Physiopedia page, we would love to hear from you – keeping our content accurate and up to date is a community effort, and your suggestions make a real difference.

Rehabilitation in critical illness is evidence-based, safe and essential. Read the full review to understand where the evidence sits and what it means for your patients.