Abstract
Research supports the provision of physical therapy intervention and early mobilization in the management of patients with critical illness. However, the translation of care from that of well-controlled research protocols to routine practice can be challenging and warrants further study. Discussions in the critical care and physical therapy communities, as well as in the published literature, are investigating factors related to early mobilization such as transforming culture in the intensive care unit (ICU), encouraging interprofessional collaboration, coordinating sedation interruption with mobility sessions, and determining the rehabilitation modalities that will most significantly improve patient outcomes. Some variables, however, need to be investigated and addressed specifically by the physical therapy profession. They include assessing and increasing physical therapist competence managing patients with critical illness in both professional (entry-level) education programs and clinical settings, determining and providing an adequate number of physical therapists for a given ICU, evaluating methods of prioritization of patients in the acute care setting, and adding to the body of research to support specific functional outcome measures to be used with patients in the ICU. Additionally, because persistent weakness and functional limitations can exist long after the critical illness itself has resolved, there is a need for increased awareness and involvement of physical therapists in all settings of practice, including outpatient clinics. The purpose of this article is to explore the issues that the physical therapy profession needs to address as the rehabilitation management of the patient with critical illness evolves.
The body of literature supporting rehabilitation, including early mobilization, as an important intervention in the management of patients with critical illness is growing. It is clear that the profoundly debilitating effects1–5 of critical illness may be mitigated when patients are not allowed to be passive early in their state of critical illness but, instead, are kept awake or are awakened regularly6,7 and, during periods of wakefulness, are engaged in activity that stimulates both body and mind.8,9 Despite the support in the literature for physical therapy intervention and early mobilization in patients with critical illness, the translation of care from that of well-controlled research protocols to routine practice can be challenging and warrants further study.
Previous review articles have summarized the evidence surrounding the effectiveness and feasibility of physical therapy intervention10 and early mobilization11,12 in the intensive care unit (ICU), and they have suggested future directions13 that the critical care community as a whole needs to explore to better understand this intervention and its application. Discussions in the critical care and physical therapy communities, as well as in the published literature, are beginning to investigate factors related to early mobilization such as transforming ICU culture,14 encouraging multidisciplinary collaboration,8,15,16 coordinating sedation interruption with mobility sessions,8 and determining the rehabilitation interventions that will most significantly improve patient outcomes.17 These are necessary topics to consider as the investigation of this intervention continues. Some variables, however, will need to be investigated and addressed specifically by the physical therapy profession. They include assessing and increasing physical therapist competence in managing patients with critical illness in professional (entry-level) physical therapist education programs and continuing postprofessional education, determining and providing an adequate number of physical therapists for a given ICU, evaluating methods of prioritization of patients in the acute care setting, and adding to the body of research to support specific functional outcome measures to be used with patients in the ICU. Additionally, because persistent weakness and functional limitations can exist long after the critical illness itself has resolved,5,18 there is a need for increased awareness and involvement of physical therapists in all settings of practice, including outpatient clinics. The purpose of this article is to investigate the issues that the physical therapy profession will need to address as the rehabilitation management of the patient with critical illness evolves.
Issues Related to Physical Therapist Competence for Practice in the ICU
Evaluating the professional training of physical therapists in the areas of acute care and critical care is important. Patients with acute illness have medical conditions that can change quickly, requiring timely and accurate assessment and modification of activity by the intervening physical therapist and titration of activity in response to change in physiological status.19 A sound knowledge of complex medical conditions, interventions, and equipment is required to ensure patient safety. Within their scope of practice, physical therapists treating patients in the ICU must be skilled in implementing interventions to maximize performance of the oxygen transport system, as well as addressing musculoskeletal, neuromuscular, and integumentary impairments. Additionally, a complete understanding of the potential negative impact of bed rest and other medical interventions on patient outcomes related to physical function and cognition is necessary to ensure that physical therapy intervention and mobilization in the ICU is prioritized appropriately. Providing safe and effective rehabilitation management of this medically complex patient population requires specific professional training, ongoing education, and assessment of competence.
Academic Preparation of Physical Therapist Students for Practice in Acute and Intensive Care
Ascertaining the curricular content of physical therapist programs that addresses the management of patients with critical illness is difficult. However, many of the components of examination and intervention for a patient with critical illness can be found in 1 of 3 documents outlining the required skills of graduates from entry-level programs and curricular components of physical therapist education. In 2005, the American Physical Therapy Association (APTA) developed a document (revised in 2009)20 outlining minimum essential skills of a physical therapist graduate. The curricular components are not organized by setting (eg, acute care) but do include content that is frequently used when assessing and treating patients in acute and critical care. A Normative Model of Physical Therapist Professional Education21 outlines values and perspectives related to physical therapy education and is intended to be a resource for the assessment of physical therapist professional education programs. The APTA Physical Therapist Clinical Education Principles22 outlines outcomes standards for physical therapist graduate performance in 29 categories. These documents and some of their content related to the physical therapist management of patients in the ICU are outlined in Table 1. Of note in Table 1 is the suggestion that achieving entry-level competency with patients who are acutely ill requires 10 to 12 weeks of clinical education.
Documents and Their Content Related to Physical Therapist Management of Patients in the Intensive Care Unita
One barrier to achieving this entry-level competency is the availability of sites for clinical education. It can be difficult for physical therapist education programs to place students in clinical experiences in acute care due, in part, to staff shortages in this area and concerns from potential clinical instructors about maintaining productivity.23 It is the responsibility of practicing physical therapists to make every effort to provide clinical experiences and serve as clinical instructors in order to sustain and promote the ongoing involvement of physical therapists in acute and critical care. One method to increase the feasibility of providing clinical experiences is the use of a 2:1 model in which 1 physical therapist supervises 2 students concurrently. This method can increase the number of clinical placements and may enhance development of student skills compared with a 1:1 model without detracting from productivity or other nonclinical time.23
Additionally, the use of human simulation as a supplement to patient interaction may assist in teaching physical therapist students the skills needed to treat patients in the ICU. Shoemaker et al24 described the use of a human simulation laboratory that included a mannequin equipped with frequently encountered lines and tubes, a monitor with telemetry, and a ventilator screen with patient data altered during a session to create a more realistic environment. Although costly, simulation systems may be a useful tool to augment learning in preparation for clinical practice in the ICU.
Clinical Competence of Physical Therapists Practicing in Acute and Intensive Care
Although physical therapist education can provide the foundation for practice in the ICU, it is still the responsibility of the practitioner and the institution to ensure patient safety by allowing only competent clinicians to provide patient care. Physical therapist licensure ensures that practicing physical therapists have met a base level of prerequisite training and knowledge. Clinical competencies aim to identify whether a practitioner possesses and can apply knowledge and skills to practice safely and effectively in a specific role.25 Health care professions, including nursing26 and pharmacy,27 use competencies in the ICU to increase proficiency and determine whether an individual possesses the skills and knowledge to practice safely in the setting. Harris28 outlined a critical care competency program for physical therapists at Yale–New Haven Hospital, developed by the facility's senior physical therapists with input from ICU physicians and nurses. Objectives of the competency are outlined in the Appendix. Additional published or standardized competencies may help guide ongoing clinical training within individual facilities.
Acute Care Physical Therapist Specialist Certification and Residency
The significance of clinical experience cannot be overlooked. The experienced physical therapist can provide care that differs from that of a less experienced clinician. In the area of cardiac and pulmonary physical therapy, more experienced (eg, >7 years of experience) clinicians demonstrate a more developed and multidimensional knowledge base and more refined approaches to clinical decision making, and they are better able to integrate context into practice.29 To recognize advanced knowledge and skills, the American Board of Physical Therapy Specialties offers board certification in 8 specialty areas of physical therapist practice. Despite the distinct body of knowledge and unique skill sets and behaviors that physical therapists in the acute care setting possess,30 there is currently no available board certification in the areas of acute care or critical care. Physical therapists who work in these settings often specialize in the area of practice in which they most often treat patients such as cardiovascular and pulmonary, geriatrics, or neurology.31 Although these areas of certification are often quite relevant to the knowledge and expertise needed to treat patients in these subspecialty areas of acute care, they may not adequately reflect the unique knowledge and skills possessed by physical therapy practitioners across the acute and critical care arenas.
In medicine, physicians complete specialty residency and fellowship programs to advance their training in specialty and subspecialty areas. Similarly, APTA credentials physical therapy residency and fellowship programs in areas such as orthopedics, neurology, and geriatrics. There are currently no physical therapy residency or fellowship programs in the areas of acute care or critical care. Efforts in the acute care physical therapy community are ongoing to describe the specialty skills of a therapist in this environment,30,31 with the ultimate goal of achieving specialist certification and facilitating the development of residencies and fellowships.
Development is needed across the continuum of learning for all physical therapist students and physical therapists in the area of critical care. It is the responsibility of those practicing in acute care to increase availability of clinical education sites, facilitate the development of clinical competencies and continuing education, and participate in advocating for and developing acute and critical care residencies, fellowships, and specialist certification. Only by advocating for our own specialty practice will we continue to provide safe and effective care to patients with critical illness and further the autonomous practice of physical therapists in the ICU.
Impact of Rehabilitation for Patients With Critical Illness on Physical Therapy and Occupational Therapy Personnel Resources
A reasonable concern when discussing physical therapist practice in the ICU or the implementation of an early mobilization program is the potential impact on personnel resources. In studies specifically describing early mobilization of patients undergoing mechanical ventilation, the addition of dedicated physical therapists and occupational therapists to the medical ICU,15 to a mobility team,16 or to a specialized respiratory ICU32 has been described. From the available literature,8,15,16,32 it is clear that more than one person is needed to safely mobilize a patient who is critically ill and undergoing mechanical ventilation. Table 2 shows the composition of published mobility teams. The number of team members and the practitioners who compose each team varies, but, in all examples, a physical therapist is included. This finding, along with a history of literature illustrating the positive impact of physical therapy intervention on patients in the ICU,19,33,34 suggests that the physical therapist should be an integral member of the critical care team.
Composition of Mobilization Teams
In a health care environment focused on saving costs, it may be tempting to rely solely on bedside nurses to mobilize patients. However, this reliance may not be preferable, as nurses have increasing demands on their time,35 and when mobilizing patients with critical illness, physical therapists achieve a higher level of mobilization than nurses.36 In addition, patients undergoing critical illness are at risk for muscle atrophy,37 deconditioning,38 and cardiopulmonary compromise,38 all of which are managed by physical therapists trained to evaluate and treat these impairments,39 particularly as they relate to functional mobility. To provide physical therapy services or create a mobility team for patients undergoing critical illness, hospital administration needs to decide whether the hiring of additional therapists is necessary or whether patient needs can be met by reallocating those currently on staff.
Making this determination can be challenging and warrants further study. Schweickert et al8 described a randomized controlled trial in which patients in the intervention group received physical therapy and occupational therapy early (beginning 1.5 days after intubation) in the course of mechanical ventilation. Ninety-five percent of the patients in the control group received physical therapy and occupational therapy intervention in the course of hospitalization—it just occurred later (7.4 days following intubation). Patients in the control group demonstrated inferior functional outcomes compared with those patients in the intervention group. So, perhaps, by intervening earlier, the demand on a physical therapist's time is offset by improvement of function early in the hospital stay, decreasing the need for physical therapy intervention later in the hospital stay. However, other studies describe an increased number of physical therapy sessions during hospitalization16 and physical therapy and occupational therapy sessions during ICU stay15 in those who participated in an early mobilization program. These data suggest that additional physical therapists and occupational therapists may be required to meet the needs of patients who may benefit from early mobilization.
If, indeed, an increase in the number of personnel is required to provide adequate physical therapy services in the ICU, implications for cost should be assessed. Morris et al16 compared the cost of care between patients who participated in an early mobilization protocol (by a team composed of a physical therapist, a critical care nurse, and a nursing assistant) and the control group. Although the analysis did not show a significant difference in total direct inpatient costs, there was an actual decreased cost for the intervention group of more than $500,000. The cost of salary and benefits for the mobility team for the duration of the project was just over $250,000. Looking at these numbers, the need for additional resources may be offset by the cost reduction associated with noted decreased ICU and hospital lengths of stay.16 Additional studies demonstrate increased ventilator-free days8 and decreased hospital and ICU lengths of stay15 in patients who participate in early mobilization, which would likely be associated with a decrease in costs.
Although research supports the positive impact of physical therapy involvement in managing patients with critical illness, data on cost and personnel resources are sparse. Additional investigations into the cost implications of adding or reallocating physical therapy resources to the ICU are needed and may support efforts to increase physical therapy involvement.
Prioritization of Patients Requiring Physical Therapist Management in the Acute and Critical Care Settings
Hospitals report difficulty recruiting physical therapists to fill vacancies, and the physical therapist vacancy rate in 2007 was 11.4%.40 These vacancies can create an environment where the demand for patient care exceeds the available physical therapy resources. In an effort to best meet the needs of all involved, therapists are tasked with formally or informally triaging or prioritizing patients. Prioritization in acute care may be divided into 2 separate considerations. The first consideration is prioritizing which patients most need to be seen across the spectrum of care. The second consideration is how the provision of physical therapy is prioritized within the ICU itself.
Prioritization of all patients in the hospital setting must be considered. With decreasing hospital lengths of stay,41 the focus on timely discharge can steer physical therapy and occupational therapy resources away from patients in the ICU and toward the patients on the step-down units or regular floor. Consultation and intervention by a physical therapist address rehabilitation needs that may allow the patient to safely discharge to the home or provide recommendations that will facilitate discharge to a rehabilitation facility.
Although this is a valuable component of the services a physical therapist provides, published literature describes improved outcomes8,15,16 and decreased ICU and hospital lengths of stay15,16 for patients who undergo early physical therapy and occupational therapy in the ICU. Therefore, providing physical therapy treatment early in the hospital stay, when some functional impairments could be mediated or prevented, will need to be considered and, perhaps, made equal or higher priority.
A shift in prioritization also may need to occur within the ICU itself. In the patient who is critically ill, functional and cognitive decline can occur rapidly.42–44 Physical therapists can expand the focus of patient care to prevention of loss of muscle strength and endurance, appropriate posture, aerobic capacity, and more in conjunction with treating deficits that may already exist. Interrupting sedation to allow early rehabilitation assessment and intervention can inhibit the development of short-term deficits8 and may improve long-term outcomes.
Additionally, the current evidence has described the impact of early mobilization on patients with a high level of function prior to admission to the ICU.8,16 There is no published literature describing the impact of early mobilization on patients with reduced baseline function. When considering how best to allocate limited resources in the ICU, additional research on the impact of early mobilization in other populations will help guide therapists toward the groups of patients most likely to benefit from such an intervention.
Patients experiencing critical illness are at risk for short-term and long-term complications that may be ameliorated by interventions provided by a physical therapist. An assessment of methods of triaging and prioritizing patients in the acute and critical care settings would be of benefit to identify the current state of practice and potential barriers to increasing physical therapy presence in the ICU. Also, assessing potential benefit to patients with various levels of baseline functional independence may help guide prioritization within the ICU itself.
Outcome Measures Used to Evaluate the Effectiveness of Physical Therapy Interventions in Patients With Critical Illness
There is increasing emphasis on the use of standardized outcome measures in physical therapy.45,46 Outcome measures quantitatively capture a patient's functional status,46 allow for meaningful reassessment and determination of effectiveness of the interventions,47 and facilitate comparison of outcomes among patients.48 Despite the benefit of standardized outcome measures, it can be difficult to identify measures that are useful and relevant to the therapist treating patients in acute and critical care. The Functional Independence Measure (FIM) was developed for use in inpatient acute rehabilitation but has been used during acute hospitalization in its full49 or abbreviated form.8,50 The FIM assesses both physical and cognitive disability and is scored on the level of assistance required to perform daily activities.
The FIM has been described as a useful measure of function in patients with respiratory failure.49 However, various studies have recognized limitations to the use of the FIM in the acute care setting.47,48 First, not all of the 18 items on the FIM are those that are assessed regularly by the physical therapists in acute care (eg, sphincter control), and, although the FIM in its entirety has been established as reliable and valid, reliability of individual components has not been described.51 Additionally, a floor effect may be seen if a shortened length of stay limits the functional improvement that can be made.47 In an attempt to better capture outcomes in the acute hospital setting, other outcome measures have been developed.
Physical therapists at the University of Rochester Medical Center trial tested a modified FIM developed at Johns Hopkins Hospital—the Johns Hopkins Hospital Function Acute Care Score (JHH-FACS)—and made changes to it based on the physical therapists' feedback.47 The resultant tool was named the University of Rochester Acute Care Evaluation (URACE). Both the JHH-FACS and the URACE attempt to improve efficiency by using only motor components of the FIM and account for type of assistive device used and distance of ambulation. The URACE further accounts for bed mobility, separate from transfers, at varying degrees of head of bed elevation. Additionally, sensitivity is increased for changes in ambulation distance and number of stairs negotiated, particularly for patients who walk only short distances or negotiate only a few stairs. Although the URACE does account for some of the more subtle functional changes that may occur in patients who are acutely ill and may be useful in this population, it does not assess changes in patients who are unable to come to sitting at the edge of the bed and has not been assessed for reliability and validity.
Additional outcome measures have been developed in an attempt to account for more subtle changes in patients who are acutely and critically ill. The Acute Care Index of Function52 was developed to assess functional levels at levels performed by patients in acute care. Making it more specific to lower levels of function, it includes rolling in bed. However, it is not specific to the cardiovascular or pulmonary impairments that are often relevant to the ICU, as it was developed for patients with neurological conditions.46 The Physical Function ICU Test (PFIT) was developed to target patients in the ICU who had undergone a tracheostomy to facilitate ventilator weaning.53 This test is more specific to patients with pulmonary dysfunction and includes assessment of endurance and muscle strength but includes only patients who are able to stand from a chair.
Physical therapists in acute care traditionally focus on functional deficits when managing patients and when making discharge recommendations, due, in part, to shortened lengths of stay and the likelihood that patients will return home at the time of hospital discharge.54 This focus on functional deficits makes the FIM and other previously described measures useful. However, in a study by Schweickert et al,8 patients were able to return to functional independence without significant improvement in muscle strength. Thus, it is possible that, while focusing on function, physical therapists are overlooking more subtle strength deficits and the opportunity to provide intervention that addresses strength impairments and to refer appropriately to outpatient services at time of hospital discharge.
Volitional muscle force can be assessed at the bedside via manual muscle testing or handheld dynamometry. The use of manual muscle tests, such as the Medical Research Council (MRC) Scale for Muscle Strength, has been validated55 and described in the assessment of patients with critical illness37 and can predict mortality, ICU and hospital lengths of stay, and duration of mechanical ventilation.56 Handheld dynamometry may aid in identifying the presence of weakness or changes in strength that are not noted in manual strength tests. Handgrip dynamometry can predict ICU-acquired paresis,57 and handheld dynamometry has good interrater reliability when measuring strength in both upper and lower extremities in patients with critical illness.58 The use of both manual strength tests and dynamometry require patients to be alert, cooperative, and able to exert maximal effort and, thus, may not be practical very early in the course of critical illness. However, as the patient recovers, strength testing may be useful in identifying impairments in strength that may contribute to the long-term deficits experienced by patients following critical illness.5
Various outcome measures are available to physical therapists assessing patients who are experiencing critical illness. Each measure has its own strengths and limitations, and further development of a tool to capture both patient status and the impact of physical therapy intervention may be needed. Ultimately, the use of a combination of functional measure and strength-specific tool will likely best capture the impairments and abilities of patients with critical illness and assist the therapist with making appropriate discharge recommendations.
Issues Related to Physical Therapist Management of Patients With Critical Illness Across the Continuum of Care
Five years following an episode of critical illness related to acute respiratory distress syndrome, patients who have recovered lung function still experience decreased functional capacity and quality of life.5 Targeted rehabilitation management of the patient post-hospitalization may be necessary to mediate the long-term impact of critical illness. Physical therapists will need to consider their role in treating patients in post-hospital settings and the best course of follow-up for patients following ICU discharge to improve outcomes.
Studies of follow-up after critical illness are limited, but a recent publication described a conference of stakeholders in long-term outcomes after ICU discharge.59 Those assembled were physicians, nurses, physical therapists, occupational therapists, and speech therapists, among others, representing organizations, including APTA, with an interest in the topic. The group acknowledged that one barrier to appropriate follow-up care may be a lack of awareness in both the general public and the medical community of the complications associated with critical illness. There are no studies investigating the knowledge base of physical therapists regarding outcomes from critical illness. A study of this type may be useful to identify areas in which further education is needed and help develop continuing education programs that target those who will treat patients after hospital discharge, including physical therapists working in inpatient rehabilitation, skilled nursing facilities, home care, and outpatient clinics.
Additionally, patients with impairments must be identified and referred to the appropriate rehabilitation professional. To this end, it may be beneficial to include physical therapists in high-acuity (pulmonary, critical care, cardiac, and thoracic surgery) physician clinics, following patients to help with timely and appropriate referral to outpatient or other rehabilitation setting.
Finally, physical therapists will be instrumental in advocating for and developing programs to address the needs of patients surviving critical illness. Pulmonary rehabilitation has been shown to increase exercise capacity and decrease hospital readmission in patients with chronic obstructive pulmonary disease.60 Participation in cardiac rehabilitation has been shown to decrease all-cause mortality and improve quality of life in patients with coronary heart disease.61 These outpatient programs consist of regular exercise and education that are individualized but delivered in a group setting over a period of weeks. A similar program may be beneficial for patients who survive critical illness. McWilliams et al62 described a 6-week outpatient program consisting of regular exercise and education designed for survivors of critical illness. Patients who participated in the program demonstrated improved functional capacity as measured by the Six-Minute Walk Test and an incremental shuttle walk test and improved scores on an anxiety and depression scale.62 Denehy et al63 described a research protocol that will evaluate a rehabilitation program that includes mobilization during the ICU and hospital stay and an 8-week outpatient rehabilitation program after hospital discharge. The results of this study have yet to be published. However, the protocol acknowledges the potential benefit of enrolling patients into a rehabilitation program similar to those programs currently available to patients with exacerbation of pulmonary disease or following an acute cardiac event.
Four additional studies have investigated the effectiveness of home-based cognitive and functional rehabilitation. Improvements in cognitive functioning and functional status were described by Jackson et al64 when patients received cognitive, physical, and functional training in-home via a telemedicine system. In a study by Jones et al,65 patients provided with a 6-week rehabilitation program via a self-directed handbook demonstrated improvements in physical function but no differences in levels of anxiety and posttraumatic stress disorder-related symptoms. Elliott et al66 and Cuthbertson et al67 reported no improvements in function66 or health-related quality of life66,67 when patients received home-based rehabilitation. The results of these studies suggest that rehabilitation may be beneficial for survivors of critical illness; however, the specific parameters of such intervention is unclear. If post-illness rehabilitation is not effective, as some of the studies suggest, it is that much more imperative that patients receive physical therapy while hospitalized in an effort to prevent functional decline. Further study is needed in this area to help determine the most effective course of rehabilitation for those recovering from critical illness.
Long-term rehabilitation management of patients following critical illness requires further attention. An effort to increase awareness and education among the general public, medical community, and rehabilitation professionals is warranted. Additional considerations are the inclusion of physical therapists in interprofessional clinics and development of exercise programs to address the needs of those who are undergoing critical illness or inclusion of these patients in existing programs.
Conclusion
Research has shown and continues to demonstrate significant benefits when patients with critical illness are engaged in physical therapy intervention and mobilization early in the course of hospitalization. However, multiple issues surrounding the execution of these interventions need to be addressed to ensure safety and availability of the intervention and to assist physical therapists in making decisions regarding its implementation and impact on long-term care. Entry-level physical therapist education programs need to expose students to information relevant to clinical practice in patients with critical illness. Clinical sites must investigate creative ways to increase offerings of clinical education experiences to students. Methods of assessing competence of practicing clinicians need to be developed. It is imperative that the specialty skills of an acute care practitioner be described in a format that allows for the development of specialist certification and advanced training programs such as residencies and fellowships. Further research is needed regarding the allocation of personnel to the ICU. Physical therapists practicing in the ICU will benefit from additional published information regarding appropriate prioritization of patients across the spectrum of acute care, including the ICU. The use of outcome measures in this population should be emphasized, including formal strength testing as appropriate and feasible. Additionally, programs addressing the ongoing rehabilitative needs of patients who have undergone critical illness need to be developed, along with promoting awareness in both the medical community and general public of the potential long-term complications of critical illness and a physical therapist's potential role in addressing these complications. With thorough and aggressive investigation of relevant topics, the resultant improvement in patient outcomes may be dramatic.
Appendix.
Footnotes
Both authors provided concept/idea/project design and writing. Dr Kress also provided data collection and analysis, project management, and consultation (including review of manuscript before submission).
- Received December 2, 2011.
- Accepted November 2, 2012.
- © 2013 American Physical Therapy Association
References
Issue highlights
- Article
- Abstract
- Issues Related to Physical Therapist Competence for Practice in the ICU
- Impact of Rehabilitation for Patients With Critical Illness on Physical Therapy and Occupational Therapy Personnel Resources
- Prioritization of Patients Requiring Physical Therapist Management in the Acute and Critical Care Settings
- Outcome Measures Used to Evaluate the Effectiveness of Physical Therapy Interventions in Patients With Critical Illness
- Issues Related to Physical Therapist Management of Patients With Critical Illness Across the Continuum of Care
- Conclusion
- Appendix.
- Footnotes
- References
- Figures & Data
- Info & Metrics