Early, progressive rehabilitation should be integrated throughout the recovery trajectory of critically ill patients, according to an invited narrative review published in Intensive Care Medicine — though the researchers emphasized that rehabilitation evidence remains heterogeneous, implementation inconsistent, and standardization of intervention reporting an unmet priority.

The review, led by Carol L. Hodgson of Monash University in Melbourne, Australia, synthesized findings from randomized controlled trials, meta-analyses, observational studies, and international clinical practice guidelines addressing rehabilitation during ICU admission, hospital recovery, and community transition following critical illness.

The researchers framed rehabilitation as a core component of contemporary ICU care, particularly for increasingly older and multimorbid ICU populations at risk for muscle wasting, frailty, cognitive decline, and long-term functional impairment. They noted that the field lacks standardized rehabilitation protocols and consistent reporting of intervention dose — including timing, intensity, duration, and frequency — which has limited the ability to synthesize findings and translate evidence into actionable clinical guidance.

ICU-acquired weakness affects more than 1 million critically ill patients globally each year and is associated with prolonged mechanical ventilation, increased morbidity and mortality, and reduced health-related quality of life, according to the review.

Across randomized trials and meta-analyses, ICU-based physical rehabilitation was generally associated with improved muscle strength and physical function, shorter ICU and hospital stays, and low adverse-event rates. However, the researchers emphasized that favorable findings from early studies have not been consistently replicated, partly because rehabilitation studies vary substantially in patient populations, intervention protocols, staffing models, and outcome measures. They noted that only through greater consistency in reporting, implementation, and evaluation of physical rehabilitation can the field fully translate evidence into reliable clinical guidance.

ABCDEF Bundle as Organizational Framework

The review positioned the ABCDEF bundle of care as a central organizational framework for ICU rehabilitation and recovery. The bundle encompasses assessment and management of pain, spontaneous awakening trials, spontaneous breathing trials, choice of analgesia and sedation, delirium prevention and monitoring, early mobilization, and family engagement and empowerment. The researchers described it as designed to mitigate muscle, nerve, and brain injury across the continuum from ICU to ward to community.

Physical Rehabilitation Modalities

The researchers described three rehabilitation modalities currently used in ICU settings: functional mobilization, cycle ergometry, and neuromuscular electrical stimulation (NMES).

Functional rehabilitation ranges from in-bed activities such as rolling or sitting at the bedside to standing and walking. Meta-analyses summarized in the review associated these interventions with improved physical function, shorter duration of mechanical ventilation, and reduced hospital length of stay, though findings remained inconsistent because of study heterogeneity.

The review discussed the CYCLE trial, which evaluated early in-bed cycling added to standard physiotherapy in mechanically ventilated patients. Although the intervention was considered safe, it did not improve physical function 3 days following ICU discharge compared with standard physiotherapy alone. A later meta-analysis of leg cycle ergometry, however, suggested improved physical function and shorter ICU and hospital stays.

Evidence supporting NMES remained mixed, according to the review, potentially because factors such as edema, sepsis, vasopressor use, and established nerve injury may limit treatment effectiveness.

The researchers stressed that rehabilitation should be individualized and physiologically monitored closely. They specifically cautioned against high-dose early mobilization during invasive mechanical ventilation in higher-risk patients, including those with diabetes, Richmond Agitation-Sedation Scale scores below −2, or vasopressor requirements.

Cognitive and Psychological Rehabilitation

The review highlighted cognitive and psychological rehabilitation as essential components of comprehensive ICU care. Delirium was identified as the most common form of acute brain dysfunction in the ICU and was associated with higher mortality, prolonged ventilation, longer ICU and hospital stays, and long-term impairments in memory, attention, and executive function.

Recommended interventions included minimizing benzodiazepine exposure when feasible, promoting daytime wakefulness and nighttime sleep, conducting structured delirium screening using tools such as the Confusion Assessment Method for the ICU or the Intensive Care Delirium Screening Checklist once per shift, encouraging family participation, and incorporating frequent patient reorientation. The researchers noted that early mobilization may itself reduce delirium risk and duration, with one randomized controlled trial reporting significant improvement in cognitive outcomes at one year.

For psychological morbidity — which may include anxiety, depression, and post-traumatic stress disorder — the review recommended structured psychological assessment beginning during ICU admission, use of ICU diaries, and professional mental health support for at least one year following discharge.

Comprehensive Recovery: Beyond Physical Function

Beyond physical rehabilitation, the review emphasized recovery strategies addressing nutrition, medication reconciliation, swallowing dysfunction, oral health, pressure injury prevention, and sensory impairment.

Nutritional guidance favored early enteral nutrition when feasible, with a graduated approach to energy and protein provision during the early acute phase — reflecting evidence that metabolic derangements in that period may limit the ability to utilize exogenous nutrition effectively. The researchers noted that combined long-term nutrition and rehabilitation interventions remain an evidence gap, with trials currently underway.

Dysphagia following extubation was identified as independently associated with morbidity and mortality, and the researchers argued that systematic swallowing screening, clinical evaluation, and rehabilitation should be incorporated into routine ICU recovery care.

Vision and hearing impairments, often overlooked in critically ill patients, can limit communication and participation in rehabilitation. The researchers noted that ensuring access to corrective devices and optimizing light and noise levels may meaningfully improve rehabilitation engagement and reduce delirium risk.

Post-ICU Discharge and Community Transition

The review highlighted persistent care fragmentation following ICU discharge. Although post-ICU recovery clinics are increasingly used — typically delivered 8 to 12 weeks after hospital discharge — the researchers noted substantial international variability in follow-up structure, staffing, and timing, leaving many patients with minimal specialized support immediately after leaving the hospital.

A systematic review cited in the paper found that nearly 80% of ICU survivors experience medication-related problems following discharge, including inappropriate continuation of acute medications such as sedatives, opioids, and gastrointestinal prophylaxis, and inappropriate discontinuation of chronic disease medications. The researchers argued that structured medication reconciliation at each care transition is essential to support rehabilitation progress and reduce downstream harm.

Digital recovery pathways combined with dedicated recovery coordinators may help address postdischarge gaps, according to the review, particularly for patients transitioning to primary care and community settings. The researchers noted that fully self-directed interventions are likely to have lower uptake than those incorporating interaction with a healthcare professional, and that expecting ICU survivors to be self-managing from the time of hospital discharge is probably unrealistic given the cognitive, physical, and emotional challenges many face.

Implementation Gaps and Emerging Technologies

Implementation of ICU rehabilitation remains inconsistent despite growing evidence and guideline support. Point-prevalence studies summarized in the review found that the proportion of ICU patients receiving no mobilization ranged from 11% to approximately 45% across international cohorts studied between 2013 and 2023. Common barriers included staffing limitations, deep sedation, cardiovascular instability, lack of protocols, and safety concerns. The researchers noted that addressing these barriers requires multicomponent implementation strategies — not education alone — including structured protocols aligned with sedation practices, interprofessional collaboration, and systematic performance monitoring.

The review examined emerging rehabilitation technologies including robotics, virtual reality, and artificial intelligence. Evidence supporting these approaches remains preliminary; robotic-assisted mobilization in pilot studies has not shown advantage over standard care, and clinical outcome studies for virtual reality in the ICU are lacking. The researchers noted that randomized studies evaluating clinical endpoints are needed before these technologies can be broadly recommended, though virtual reality's low cost and engaging nature may offer potential for combined physical and cognitive benefit.

The review also highlighted the ongoing international ERUPT study (NCT06960642), which is applying machine learning methods to evaluate mobilization practices and outcomes across a large cohort of critically ill patients.

Conclusion

"Routine, early, and comprehensive ICU rehabilitation is both safe and essential," the researchers wrote, while also calling for better standardization of rehabilitation protocols, more precise reporting of intervention dose, and implementation-focused research to improve uptake and equity across diverse ICU settings.

Disclosures: Hodgson and Stefan J. Schaller are section editors for Intensive Care Medicine and were not involved in the review or selection process for the manuscript. Several researchers reported grants, honoraria, unrestricted grant funding, or equipment support from organizations including Springer Verlag GmbH, Advanz Pharma GmbH, Fresenius Kabi GmbH, Nutricia Australia, Johns Hopkins rehabilitation conferences, and Restorative Therapies.

Source: Intensive Care Medicine