Research Report

Physical Therapist Practice in the

Intensive Care Unit: Results of a

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National Survey
Daniel Malone, Kyle Ridgeway, Amy Nordon-Craft, Parker Moss,
Margaret Schenkman, Marc Moss
D. Malone, PT, PhD, CCS, Depart-
ment of Physical Medicine and
Background. Early rehabilitation improves outcomes, and increased use of phys- Rehabilitation, University of Colo-
ical therapist services in the intensive care unit (ICU) has been recommended. Little rado Denver, 13121 E 17th Ave,
is known about the implementation of early rehabilitation programs or physical Aurora, CO 80045 (USA). Address
therapists’ preparation and perceptions of care in the United States. all correspondence to Dr Malone
at: daniel.malone@ucdenver.edu.
Objective. A national survey was conducted to determine the current status of K. Ridgeway, PT, DPT, Depart-
physical therapist practice in the ICU. ment of Physical Therapy, Univer-
sity of Colorado Hospital, Aurora,
Colorado.
Design. This study used a cross-sectional, observational design.
A. Nordon-Craft, PT, DSc, Depart-
Methods. Self-report surveys were mailed to members of the Acute Care Section ment of Physical Medicine and
of the American Physical Therapy Association. Questions addressed staffing, training, Rehabilitation, University of Colo-
rado Denver.
barriers, and protocols, and case scenarios were used to determine perceptions about
providing rehabilitation. P. Moss, Pulmonary Sciences and
Critical Care Medicine, University
of Colorado Denver.
Results. The response rate was 29% (667/2,320). Staffing, defined as the number
of physical therapists per 100 ICU beds, was highest in community hospitals (aca- M. Schenkman, PT, PhD, FAPTA,
demic: median⫽5.4 [range⫽3.6 –9.2]; community: median⫽6.7 [range⫽4.4 –10.0]) Department of Physical Medicine
and Rehabilitation, University of
and in the western United States (median⫽7.5 [range⫽4.2–12.9]). Twelve percent of Colorado Denver.
physical therapists reported no training. Barriers to providing ICU rehabilitation
included insufficient staffing and training, departmental prioritization policies, and M. Moss, MD, Pulmonary Sci-
ences and Critical Care Medicine,
inadequate consultation criteria. Responses to case scenarios demonstrated differ- University of Colorado Denver.
ences in the likelihood of consultation and physical therapists’ prescribed frequency
and intensity of care based on medical interventions rather than characteristics of [Malone D, Ridgeway K, Nordon-
Craft A, et al. Physical therapist
patients. Physical therapists in academic hospitals were more likely to be involved in practice in the intensive care unit:
the care of patients in each scenario and were more likely to perform higher-intensity results of a national survey. Phys
mobilization. Ther. 2015;95:1335–1344.]

© 2015 American Physical Therapy

Limitations. Members of the Acute Care Section of the American Physical Ther- Association
apy Association may not represent most practicing physical therapists, and the 29%
Published Ahead of Print:
return rate may have contributed to response bias.
June 4, 2015
Accepted: May 21, 2015
Conclusions. Although staffing was higher in community hospitals, therapists in Submitted: October 6, 2014
academic and community hospitals cited insufficient staffing as the most common
barrier to providing rehabilitation in the ICU. Implementing strategies to overcome
barriers identified in this study may improve the delivery of ICU rehabilitation
services.
Post a Rapid Response to
this article at:
ptjournal.apta.org

October 2015 Volume 95 Number 10 Physical Therapy f 1335

Physical Therapist Practice in the ICU
C
omplications of critical illness
include intensive care unit
(ICU)–acquired weakness,
neuropsychiatric abnormalities, im-
paired functional mobility,
decreased quality of life, and high
costs of health care use.1–5 Physical
therapist services provided in the
ICU, including early mobilization,
have been reported to improve func-
tional mobility, promote weaning
from mechanical ventilation, and
reduce hospital readmissions.6 –9 As a
result, increased use of physical ther-
apist services in the ICU have been
recommended.5,10,11
Surveys of ICU physical therapists in
Europe,10,12 Australia,13,14 and Can-
ada15 have described variations in
practice as well as differences in
staffing and training between coun-
tries and regions. For example, Euro-
pean and Australian physical
therapist practice includes both
respiratory treatment and rehabilita-
tion treatment of patients in the ICU.
Physical therapists in Sweden, the
Netherlands, Switzerland, and Aus-
tralia are rarely involved with wean-
ing patients from mechanical venti-
lation, whereas greater than 50% of
physical therapists in Belgium and
Portugal routinely participate in
weaning patients from mechanical
ventilation.10,13 Canadian physical
therapists reported ambulation as an
intervention 56% of the time, on
average. Regionally, however, ambu-
lation was implemented 100% of the
time in Saskatchewan and 33% of the
time in Nova Scotia.15 In Germany,
larger proportions of patients
were mobilized out of bed in com-
munity hospitals than in university
and university-affiliated hospitals.12
Regarding training, 29% of European
physical therapists reported post-
graduate specialization in ICU ther-
apy, and 43% reported postgraduate
specialization in respiratory therapy,
the largest percentage being from
the United Kingdom.10
1336 f Physical Therapy Volume 95
With regard to the United States, we
published a survey in 2009 that iden-
tified functional mobility retraining
and therapeutic exercise as the most
common interventions performed in
the ICU by physical therapists.16
Additionally, we reported that
patients with neurological and
trauma diagnoses were more likely
to receive physical therapist services
than patients with medical diagno-
ses.16 The evidence for ICU-based
rehabilitation continues to evolve,
and physical therapists are now rec-
ommended to play an integral role in
the care of patients recovering from
critical illness.5,7,17 In the United
States, however, there is a paucity of
information describing how ICU-
based physical therapist services are
implemented, and currently there
are no descriptions of physical ther-
apists’ background (demographics,
including age, years of licensure, and
years of ICU experience), training
(methods of gaining the knowledge,
skills, and attributes needed to work
in the ICU), or perceptions about
providing care to patients who are
critically ill.
The purpose of this study was to
characterize current physical thera-
pist practice, specifically, practitio-
ner demographics, ICU staffing pat-
terns, methods of training for ICU
practice, barriers to providing reha-
bilitation services, and the influence
of characteristics of patients on phys-
ical therapists’ decision making
regarding their plan of care. Addi-
tionally, the responses of physical
therapists from academic and com-
munity hospitals and different
regions of the United States were
compared. The results of this survey
identified barriers to the provision of
rehabilitation that could be over-
come, possibly improving ICU reha-
bilitation service delivery.
Number 10
Method
Participants
We mailed self-administered surveys
to all 2,320 physical therapist mem-
bers of the Acute Care Section (ACS)
of the American Physical Therapy
Association (APTA). The APTA is a
professional membership organiza-
tion representing more than 88,000
member physical therapists, physical
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therapist assistants, and students.
The ACS is 1 of 18 sections of APTA.
To join the ACS, one must belong to
APTA and pay national, chapter, and
section membership fees. Members
of the ACS have clinical, administra-
tive, or research interests in acute
care practice.
Survey Development
Questions and case scenarios were
developed through an iterative pro-
cess involving physical therapists
with ICU experience, physical ther-
apist academicians, and critical care
physicians. A preliminary survey was
distributed to several physical thera-
pists with ICU experience nationally
and internationally to assess for ease
of completion. Modifications based
on the clinicians’ suggestions
resulted in the final version of the
survey.
Survey Content
The final, 65-item questionnaire
required 15 minutes to complete
(eAppendix, available at ptjournal.
apta.org). The survey was divided
into 2 sections. Section 1 addressed
Available With
This Article at
ptjournal.apta.org
• eAppendix: Survey of Acute Care
Physical Therapists/Physiotherapists
Regarding Intensive Care
Rehabilitation
• eFigure: Regional Breakdown of
Training of Physical Therapists
October 2015

Table 1.
Six Case Scenariosa
Trach or
Case Diagnosis Intub
1 Stroke Trach
2 ARF Trach
3 ARF Intub
4 ARF Trach
5 ARF Trach
6 ARF Trach
a
Trach⫽tracheostomy tube; Intub⫽oral endotracheal tube; FIO2⫽fraction of inspired oxygen;
PEEP⫽positive end-expiratory pressure; CRRT⫽continuous renal replacement therapy via central venous
access (nonfemoral); vasopressors⫽low, constant infusion of dobutamine, vasopressin, dopamine, or
epinephrine; ARF⫽acute respiratory failure.
b
Low FIO2/PEEP was defined as FIO2⫽0.40 (40% oxygen) and PEEP⫽5 cm H2O pressure. High FIO2/
PEEP was defined as FIO2⫽0.70 (70% oxygen) and PEEP⫽10 cm H2O pressure.
the following: demographics of the
hospital or ICU and physical thera-
pists (10 items), staffing patterns (2
items), training methods for working
in the ICU (3 items), self-confidence
working in the ICU (5 items), the
presence of specific consultation
and treatment guidelines (2 items),
and perceived barriers to providing
rehabilitation services in the ICU (6
items). The adequacy of training and
barrier identification were assessed
with a 5-point Likert scale ranging
from 1 (strongly disagree) to 5
(strongly agree). Formal training was
defined as ICU instruction that
occurred as part of the entry-level
physical therapist degree, postgradu-
ate residency or fellowship program,
or continuing education courses.
Informal training was defined as
on-site, facility-based training;
senior staff mentorship; or comple-
tion of department-based compe-
tency requirements.
Section 2 of the survey addressed
physical therapists’ perceptions of
rehabilitation practices by eliciting
responses to 5 questions related to
each of 6 hypothetical case scenar-
ios. The complexity of patient care
was influenced by the addition of a
variable such as an artificial airway
(endotracheal tube or tracheostomy
tube), an altered mechanical ventila-
October 2015
Physical Therapist Practice in the ICU
FIO2/PEEPb
Ratio CRRT Vasopressors
Low No No
Low No No
Low No No
High No No
Low Yes No
Low No Yes
tion setting (positive end-expiratory
pressure or supplemental oxygen),
or medical interventions to maintain
hemodynamic stability (vasopressors
or continuous renal replacement
therapy) (Tab. 1). Cases differed by
one variable only. All patients were
described as being awake, alert, and
able to follow instructions and were
defined as weak. Questions in sec-
tion 2 addressed the following: the
likelihood of physical therapist con-
sultation, frequency of care pre-
scribed by physical therapists, phys-
ical therapists’ confidence in and
perception of the benefit of perform-
ing various interventions, identifica-
tion of the single most beneficial
intervention category, and physical
therapists’ confidence in mobilizing
patients out of bed as part of a phys-
ical therapy intervention session.
Confidence in mobilization was
assessed with a 5-point Likert scale
ranging from 1 (strongly disagree) to
5 (strongly agree).
Survey Administration
Surveys were mailed in March 2013
and included a self-addressed,
stamped envelope for return. Two
follow-up postcard reminders were
sent at 6-week intervals, and remind-
ers were posted to the ACS listserve
to facilitate completion of the sur-
vey. No incentives were offered for
Volume 95
return of the survey. Responses were
recorded for total respondents and
further categorized on the basis of
the primary hospital at which the
therapists were employed (ie, aca-
demic or community) and the region
of the United States in which they
were employed. Regions were
defined as West, Midwest, Northeast,
Southeast, and Southwest.
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Survey Analysis
Normally distributed data were
expressed as means (95% confidence
intervals [CI]), and data that
were not normally distributed were
expressed as medians (interquartile
ranges). Means of the Likert scale
data were included in the analysis of
physical therapists’ confidence in
their ability to provide rehabilitation.
Chi-square tests of independence
were used to examine categorical
variables at baseline, including anal-
yses of the effects of regional differ-
ences in the percentages of physical
therapists with formal training and
the type of hospital (academic or
community) on the following out-
comes: percentage of physical ther-
apists with formal training, percent-
age of hospitals with established
competency requirements or guide-
lines for physical therapist consulta-
tion, presence of barriers to physical
therapy, and frequency of physical
therapy in the 6 case scenarios.
When the data were normally distrib-
uted, t tests were used to compare
continuous characteristics of 2
groups, and analyses of variance
were used when there were more
than 2 groups. These analyses were
used to determine the effect of phys-
ical therapists’ confidence in their
ability to provide rehabilitation. For
all other univariate analyses, non-
parametric testing was used because
the data were not normally distrib-
uted. Multivariate logistic regression
was used to evaluate the association
between regions of the United States
and formalized training (yes or no).
Other potential independent predic-
Number 10 Physical Therapy f 1337
Physical Therapist Practice in the ICU
Figure.
Regional breakdown of physical therapist staffing (number of therapists per 100
intensive care unit beds, shown as median [interquartile range]).
tors included in the analyses were
type of hospital (academic or com-
munity) and length of employment
(in number of years). JMP software
(SAS Institute Inc, Cary, North Caro-
lina) was used for all analyses, and a
P value of less than .05 was consid-
ered statistically significant.
Role of the Funding Source
This study was funded by Nation-
al Institutes of Health grant
R01NR011051. The NIH had no role
in study design; in data collection,
analysis, or interpretation; in writing
the manuscript; or in the decision
to submit the manuscript for
publication.
Results
General Demographics
A total of 2,320 surveys were mailed,
and 667 were returned, for an overall
Table 2.
Training of Physical Therapistsa
Overall
Training (Nⴝ512)
Formal 31.8 (163)
Informal 55.9 (286)
None 12.3 (63)
a
The P value for academic hospitals versus community hospitals was .02.
1338 f Physical Therapy Volume 95
response rate of 29%. Of the 667
respondents, 113 did not complete
the survey because they did not cur-
rently practice in the acute care or
ICU setting, or the survey was not
deliverable because of an inaccurate
address. Therefore, 554 surveys
were included in the final analysis.
Completed surveys represented 47
of the 50 states (missing were Dela-
ware, Rhode Island, and Hawaii)
and the District of Columbia. A total
of 37% (n⫽205) of the respondents
were from academic hospitals,
and the remaining 63% (n⫽349)
were from community hospitals.
Regionally, 21% (n⫽117) of respon-
dents were from the West, 22%
(n⫽131) were from the Midwest,
18% (n⫽98) were from the North-
east, 22% (n⫽118) were from the
Southeast, and 14% (n⫽75) were
from the Southwest (Figure).
% (n) of Physical Therapists
Academic Hospital Community Hospital
(nⴝ183) (nⴝ329)
27.3 (50) 34.3 (113)
63.9 (117) 51.4 (169)
8.7 (16) 14.3 (47)
Number 10
Staffing
Defined as the number of physical
therapists per 100 hospital beds or
ICU beds and reported as medians
(interquartile ranges), staffing was
2.4 (1.7–3.3) for the hospital and 6.3
(4.0 –10.0) for the ICU (P⬍.001).
Academic hospitals had lower ICU
staffing than community hospitals
(academic:5.4[3.6 –9.2];community:
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6.7 [4.4 –10.0]; P⫽.005). Regionally,
ICU staffing was highest in the West
(7.5 [4.2–12.9]) and lowest in the
Southeast (5.6 [3.6 –9.5]) and South-
west (5.0 [3.0 – 8.0]) (P⫽.009)
(Figure).
Physical Therapist Experience
and Training
With regard to experience—which
was reported as medians (interquar-
tile ranges)—respondents had, on
average, 13 (5.5–22) years of experi-
ence, 10 (5–17) years of experience
working in the acute care hospital
setting, and 7.8 (3–15) years of expe-
rience working in the ICU. Physical
therapists at academic hospitals had
greater acute care experience (aca-
demic: 13.2 years [11.9 –14.4]; com-
munity: 11.0 years [10.1–12.0];
P⫽.009) and greater ICU experience
(academic: 10.9 years [9.7–12.2];
community: 9.3 years [8.3–10.2];
P⫽.03).
Only 31.8% of the physical therapists
had received formal ICU training.
Most of the respondents had
received hospital-based informal
training (55.9%), and 12.3% had
received no formal or informal train-
ing (Tab. 2). Physical therapists at
community hospitals reported a
higher percentage of formal training
(34.3%) but also a higher percentage
of no training (14.3%) than those at
academic hospitals (P⫽.02). Physical
therapists from academic settings
reported that their departments
were more likely to have established
competency requirements than
those from community settings (aca-
demic: 51.7%; community: 28.2%;
October 2015

Table 3.
Barriers to Providing Physical Therapy in the Intensive Care Unit
% (n) of Physical Therapists
Overall
Barrier (Nⴝ550)
Insufficient staffing 44.2 (243)
Lower prioritization 36.7 (202)
Lack of consultation criteria 35.1 (193)
Inadequate training of physical 28.6 (157)
therapists
Lack of perceived importance 24.7 (136)
Sedation of patients 24.2 (133)
P⫽.0001). Regionally, the percent-
age of physical therapists with for-
mal training was highest in the Mid-
west, compared with other regions
of the United States (eFigure, avail-
able at ptjournal.apta.org). These
regional training differences re-
mained in a multivariable analysis
adjusting for type of hospital and
length of employment (P⫽.005).
Physical therapists had confidence in
their ability to provide rehabilitation
in the ICU (X⫽4.4 [95% CI⫽4.3,
4.4]), with a significant difference
between academic and community
settings (academic: X⫽4.5 [95%
CI⫽4.4, 4.6]; community: X⫽4.3
[95% CI⫽4.2, 4.4]; P⫽.0007). Physi-
cal therapists also reported under-
standing mechanical ventilation
(X⫽3.9 [95% CI⫽3.8, 4.0]), with
physical therapists in academic set-
tings reporting greater understand-
ing than those in community settings
(academic: X⫽4.1 [95% CI⫽4.0,
4.3]; community: X⫽3.7 [95%
CI⫽3.6, 3.8]; P⬍.0001). Whether
these differences are meaningful is
questionable.
Physical Therapist Consultation
Overall, 38.6% of respondents
reported facility-based guidelines for
ICU consultation, and 43.5% of phys-
ical therapists reported specific
guidelines for session termination.
There were no differences between
academic and community settings.
October 2015
Physical Therapist Practice in the ICU
Academic Community
Hospital (A) Hospital (C) P Value for
(nⴝ204) (nⴝ346) A vs C
50.1 (103) 40.5 (140) .02
37.8 (77) 36.1 (125) .7
29.9 (61) 38.2 (132) .05
27.0 (55) 29.5 (102) .5
21.6 (44) 26.6 (92) .18
17.7 (36) 28.0 (97) .005
Barriers
The percentages of respondents
who agreed or strongly agreed with
the common barriers to providing
physical therapist services in the ICU
are shown in Table 3. Overall, the
barriers chosen most frequently
were insufficient staffing, lower
prioritization of the ICU, and lack of
specific consultation criteria for
physical therapist services. Physical
therapists in academic settings noted
insufficient staffing as a more fre-
quent barrier than physical thera-
pists in community settings. Physical
therapists in community hospitals
identified sedation of patients as a
more frequent barrier than physical
therapists in academic hospitals.
Additional barriers provided by
respondents (n⫽280) included
scheduling conflicts, such as a
patient receiving bedside dialysis or
being transported off the floor for
diagnostic testing (19%, n⫽53), and
inadequate equipment (19%, n⫽53).
Perceptions of Physical
Therapy Care
The 6 case scenarios (Tab. 1)
showed that a physical therapy con-
sultation was less likely for patients
with more complex medical condi-
tions. If physical therapists were
consulted, then the prescribed fre-
quency and intensity of care also
decreased as the complexity
increased (Tab. 4). For example,
patient mobilization was limited,
Volume 95
with ambulation being included in
the care plan for only 12.4% of
patients on vasopressors. Therapists
were asked to predict what interven-
tion would have the most positive
impact on patient outcomes; func-
tional mobility training was
expected to be the most beneficial
intervention, and the next most ben-
eficial was expected to be therapeu-
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tic exercises (strengthening or aero-
bic). However, this prediction was
influenced by characteristics of
patients, as exercise was predicted
to have a more positive impact for
patients with more complex medical
conditions. Finally, physical thera-
pists who worked in academic hos-
pitals believed that they were more
likely to be involved in the care of
patients in each scenario and were
more likely to perform higher-
intensity mobilization, such as trans-
fers out of bed and ambulation, than
those who worked in community
hospitals (Tab. 5).
Discussion
Physical therapy interventions aim to
ameliorate physical and neurocogni-
tive morbidity associated with criti-
cal illness and are safe and feasible in
patients in the ICU.6 –9 Our research
revealed differences in current ICU-
based physical therapist practice
regionally and between academic
and community hospital settings.
Physical therapists frequently cited
staffing, training, prioritization poli-
cies, sedation of patients, scheduling
conflicts, and limited consultation
criteria as barriers to rehabilitation in
the ICU. Equipment in the ICU and
the complexity of patients’ medical
conditions affected physical thera-
pists’ decision making and confi-
dence in progressive mobilization.
On average, physical therapists who
worked in the ICU had a mean of 7.8
years of direct ICU experience; pre-
dictably, the type of training most
frequently cited in the present sur-
vey was informal training relying on
Number 10 Physical Therapy f 1339
Physical Therapist Practice in the ICU

Table 4.
Physical Therapists’ Responses to 6 Case Scenariosa

Case 1: Case 3: Case 4: High Case 6:

Parameter Stroke Case 2: ARF Intubation FIO2/PEEPb Case 5: CRRT Vasopressors

Percentage of physical therapist 100 (80–100) 90 (60–100) 75 (25–95) 50 (20–90) 70 (30–92) 40 (0–74)
consultations, median
(interquartile range)c
Treatment frequency, d/wk, 5 (5–6) 5 (4–6) 5 (4–6) 4.5 (3–5) 4 (4–5.5) 4 (2.5–5)
median (interquartile range)d

Bed exercises 93.6 (501/535) 89.7 (489/545) 93.0 (478/514) 93.6 (436/466) 90.3 (449/497) 93.9 (366/394)

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Sittinge 95.3 (510/535) 94.7 (516/545) 83.1 (427/514) 74.4 (347/466) 84.5 (420/497) 66.2 (261/394)
e
Standing 71.4 (382/535) 81.3 (443/545) 64.2 (330/514) 42.5 (198/466) 63.5 (315/496) 42.6 (168/394)

Transfer out of bede 72.3 (387/535) 82.8 (451/545) 62.5 (321/514) 41.2 (192/466) 59.6 (296/497) 40.0 (156/394)
e
Ambulation 35.8 (192/535) 50.8 (277/545) 31.1 (160/514) 16.7 (78/466) 31.4 (156/497) 12.4 (49/394)

Functional mobility retraining, %f 82.8 88.2 72.8 47.0 41.9 48.4

g
Therapeutic exercises, % 5.9 6.0 7.3 17.0 15.0 20.9
a
Data are reported as percentages (numbers) unless otherwise indicated. ARF⫽acute respiratory failure; FIO2⫽fraction of inspired oxygen; PEEP⫽positive
end-expiratory pressure; CRRT⫽continuous renal replacement therapy via central venous access (nonfemoral); vasopressors⫽low, constant infusion of
dobutamine, vasopressin, dopamine, or epinephrine.
b
High FIO2 was defined as FIO2⫽0.70 (70% oxygen) and PEEP⫽10 cm H2O pressure.
c
The frequency of consultation differed among the cases (P⬍.0001).
d
The frequency of treatment differed among the cases (P⬍.0001).
e
Progressive mobility (sitting to standing to transfer out of bed to ambulation) differed among the cases (P⬍.0001).
f
The predicted benefit of functional mobility retraining decreased from cases 1 through 6 (P⬍.0001).
g
The predicted benefit of therapeutic exercises increased from cases 1 through 6 (P⬍.0001).

mentorship and department-based
competency requirements. The high
prevalence of informal training was
expected because formal training
options are limited, with only 3 car-
diovascular and pulmonary residen-
cies and only 2 critical care fellow-
ships currently credentialed by the
American Board of Physical Therapy
Residency and Fellowship Educa-
tion.18 Interestingly, physical thera-
pists working in community settings
reported a higher percentage of for-
mal training but also a higher per-
centage of no training than those
working in academic settings.
These data reflect the need for con-
tinual internal and external compe-
tent mentorship. “Competent men-
torship” implies that the mentor is
truly competent in the knowledge,
skills, and abilities that will enable
safe and successful physical therapist
practice in the ICU. Anecdotally,
mentoring tasks are often delegated
to senior staff members, but this
informal training has important ram-
ifications for the successful prepara-
tion of future physical therapists for
work in the ICU in the United States
and elsewhere. The 2010 Physical
Therapy Workforce Project revealed
that hospitals can expect a turnover
rate of approximately 12%, including
junior staff and senior staff equally.19
The practice analysis concluded that
staffing shortages and consistent
turnover mean that more time must
be devoted to direct patient care,
limiting the ability of senior staff to
mentor junior staff.19 To meet the
needs of patients who are critically
ill and guide and develop the special-
ized practice of ICU-based physical
therapy, a multifaceted approach is
required. For example, entry-level
physical therapy curricula and clini-
cal education should include ICU-
based objectives and student expo-
sures,20 clinical competency
requirements and practice guide-
lines should be developed in hospital
settings and subjected to peer
review,21 continuing education
courses should be based on current
practice guidelines and assessed by
content experts, and residencies and
fellowship programs need to be
expanded.
Staffing in the ICU was more limited
in academic hospitals than in com-
munity hospitals, and regional differ-
ences were also observed. These
findings confirm that insufficient
staffing remains a frequently cited
and consistent barrier to providing
rehabilitation to patients in the
ICU.10,17 Although patient outcomes
were not addressed in the present
survey, it will be important to exam-
ine whether limited staffing has a
negative effect on patient outcomes,
similar to data for ICU physicians and
nurses.22,23 Early rehabilitation stud-
ies by Bailey et al,6 Schweickert et
al,7 and Morris et al9 advocated for
daily physical therapist services, and
Burtin et al8 provided bedside inter-
ventions 5 days per week. Consistent
with these recommendations, daily
physical therapist services after joint
arthroplasty,24 after trauma to the

1340 f Physical Therapy Volume 95 Number 10 October 2015

 October 2015
Table 5.
Physical Therapists’ Responses to 6 Case Scenarios Stratified by Academic Hospital (A) Versus Community Hospital (C)a

Case 1: Stroke Case 2: ARF Case 3: Intubation Case 4: High FIO2/PEEPb Case 5: CRRT Case 6: Vasopressors

Parameter A C A C A C A C A C A C

Percentage of 90 (87–93) 81 (78–84) 86 (83–89) 71 (70–75) 69 (65–73) 57 (53–61) 63 (59–68) 48 (43–51) 67 (63–71) 57 (53–61) 53 (47–58) 35 (31–39)
physical
therapist
consultations,
median
(interquartile
range)c

Treatment 5.1 (4.9–5.2) 5.6 (5.4–5.7) 4.9 (4.7–5.0) 5.3 (5.2–5.4) 4.6 (4.4–4.8) 4.9 (4.8–5.1) 4.1 (3.9–4.3) 4.2 (4.0–4.4) 4.3 (4.1–4.5) 4.7 (4.5–4.9) 3.7 (3.5–4.0) 3.7 (3.5–4.0)
frequency,
d/wk, median
(interquartile
range)d

Bed exercises 94 93 89 90 91 94 93 94 91 90 92 94
e
Sitting 96 95 97 93 86 81 81 70 89 81 74 60

Standinge 75 69 88 77 74 58 56 34 70 60 56 33

Transfer out of 76 70 89 79 71 57 55 32 69 54 51 31
bede

Ambulatione 41 32 63 43 39 25 23 13 38 27 14 11

Functional 84 83 90 87 80 69 53 43 69 66 59 42

Volume 95
mobility
retraining, %

Therapeutic 7 5 6 6 10 14 16 18 15 16 18 22
exercises, %

Number 10
a
Data are reported as percentages unless otherwise indicated. ARF⫽acute respiratory failure; FIO2⫽fraction of inspired oxygen; PEEP⫽positive end-expiratory pressure; CRRT⫽continuous renal replacement
therapy via central venous access (nonfemoral); vasopressors⫽low, constant infusion of dobutamine, vasopressin, dopamine, or epinephrine.
b
High FIO2 was defined as FIO2⫽0.70 (70% oxygen) and PEEP⫽10 cm H2O pressure.
c
The frequency of consultation differed for A versus C (P⬍.0001).
d
The frequency of treatment differed for A versus C (P⫽.01).
e
Progressive mobility (sitting to standing to transfer out of bed to ambulation) differed for A versus C (P⬍.0001).

Physical Therapy f
Physical Therapist Practice in the ICU

1341
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Physical Therapist Practice in the ICU
pelvis or spine,25 or for patients with
neurological issues26 decreased the
length of stay. Given limited
resources, physical therapists cannot
meet the recommendation of daily
interventions. Limited staffing may
be one reason why daily physical
therapist interventions were not rec-
ommended by the respondents for
any of the case scenarios. In a Euro-
pean survey addressing ICU-based
physical therapist services, greater
than 75% of ICUs were reported to
have at least one designated physical
therapist who was equally responsi-
ble for respiratory therapy manage-
ment and early mobilization.10
Increasing staffing to meet the needs
of the ICU population will require
reallocation of hospital resources but
is supported by evidence demon-
strating improved patient morbidity
and positive financial incentives.17
Consistent with other ICU literature,
barriers identified in the present
survey included sedation of
patients,27–29 lack of specific consul-
tation criteria,16 and scheduling con-
flicts related to the timing of medical
procedures.30,31 Our 2009 survey
showed that only 10% of ICUs had
established guidelines for physical
therapist consultation, whereas the
current survey revealed that 40% of
ICUs had such guidelines, indicating
that changes in ICU practice are
ongoing.16 Other barriers identified
in the present survey, such as staff-
ing, prioritization policies, consulta-
tion criteria, and training of physical
therapists, likewise should be sur-
mountable but will require changes
in physical therapy department staff-
ing and prioritization standards,
direct discussions with ICU medical
and nursing directors to establish
consultation and intervention guide-
lines, and changes in educational
models to improve physical therapist
training and readiness to work in the
ICU.
1342 f Physical Therapy Volume 95
With regard to physical therapists’
perceptions and treatments pro-
vided, the case scenarios demon-
strated that physical therapists
would most commonly perform bed-
level exercises. Their confidence in
progressive mobilization would be
influenced by the presence of endo-
tracheal tubes, central venous
access, and supportive technology,
such as mechanical ventilation and
renal replacement therapy. For
example, although each of the case
scenarios indicated that the patient
was stable, ambulation would be
included in the care plan for only a
minority of patients (Tab. 4). Studies
have demonstrated that ambulation
is feasible and safe for patients who
have respiratory failure and are orally
intubated or receiving life-sustaining
therapies, such as extracorporeal
membrane oxygenation.32,33 In the
present survey, progressive mobiliza-
tion, including ambulation, was
more likely to occur in academic
hospitals. This finding may have
been due to greater experience of
physical therapists in acute care and
ICU environments, the presence of
departmental competency require-
ments, or greater access to ICU-
related education that occurs as part
of grand rounds or physician training
programs.
Functional mobility retraining was
predicted to be most advantageous
for patients with the least compli-
cated scenarios and less beneficial as
the complexity of patients’ medical
conditions increased. Therapeutic
exercise was believed to be more
valuable with increasing complexity
of patients’ medical conditions.
These findings are consistent with
those of recent studies with pediat-
ric and adult populations. In a Cana-
dian survey of children who were
critically ill, passive range of motion
was the intervention that was most
frequently applied and gait training
was infrequently performed.34 Simi-
larly, in 1-day point-prevalence stud-
Number 10
ies conducted across Germany, Aus-
tralia, and New Zealand, patients
who required mechanical ventilation
were rarely mobilized out of bed.
The likelihood of being mobilized
out of bed was still lower for patients
who had an endotracheal tube.12,35
Our study had several important lim-
itations. Members of APTA and the
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ACS may not represent most
hospital-based physical therapists,
and the return rate was 29%. There-
fore, our results were prone to non-
responder bias, and the data may not
represent the entire population stud-
ied.36 The use of survey response
rates has been noted to be a com-
mon but ineffective way to deter-
mine nonresponder bias, and com-
parative information about the
population of interest may allow
greater generalizability.36,37 Addi-
tionally, according to the 2013 Acute
Care Section Demographic Profile
Summary, 1,623 members of the ACS
reported practicing in the acute care
setting for an average of 15.8 years
(Acute Care Section, American Phys-
ical Therapy Association; personal
communication; April 29, 2014). In
the present study, the data presented
were only from respondents who
worked in the acute care setting, and
these respondents had 13 years of
experience. Therefore, the respon-
dents in the present study were sim-
ilar to practicing members of the
ACS, and our 667 respondents repre-
sented 41% of practicing members of
the ACS—a more robust return rate.
Furthermore, despite the relatively
low response rate, a post hoc analy-
sis of the survey return rate (667 of
2,320 surveys sent) suggested that
the results were accurate (95% con-
fidence with 3% error). Additionally,
self-report surveys may tend to
underreport behaviors deemed inap-
propriate or overreport ideal behav-
iors due to bias. Self-report surveys
have the advantage that respondents
are providing their own personal
October 2015

perspective of themselves and their
individual practice. Finally, the sur-
vey would have been improved by
the inclusion of operational defini-
tions for several items (eg, facility-
based training, departmental compe-
tency requirements, and likelihood
of physical therapist consultation)
and the addition of questions
addressing delirium as a barrier and
the presence of rehabilitation tech-
nicians in the ICU.
The findings of the present survey
provide insight into physical thera-
pist practice in the United States and
perceptions of care and reveal differ-
ences between academic and com-
munity settings as well as regionally.
Consistent with prior reports, insti-
tutional and departmental barriers
limiting early ICU rehabilitation
remain pervasive. Identification of
barriers is an initial step in develop-
ing quality improvement initiatives
to facilitate the delivery of physical
therapist services for patients who
are critically ill. The findings of the
present study suggest that continued
efforts to develop strategies to
ensure adequate physical therapist
staffing in the ICU, increased aware-
ness of the evidence supporting ICU
rehabilitation for improved patient
functional outcomes and institu-
tional cost savings, the development
of ICU rehabilitation service consul-
tation criteria, and improvements in
the training of physical therapists for
ICU practice are warranted.
Dr Malone, Dr Ridgeway, Dr Nordon-Craft,
Dr Schenkman, and Dr M. Moss provided
concept/idea/research design, fund procure-
ment, and institutional liaisons. Dr Malone,
Dr Nordon-Craft, and Dr Schenkman pro-
vided writing. Dr Malone and Mr P. Moss
provided data collection and project man-
agement. Dr Malone provided data analysis.
Mr P. Moss provided administrative support.
Dr Ridgeway and Dr Nordon-Craft provided
consultation (including review of manuscript
before submission).
This study was approved by the Colorado
Multiple Institutional Review Board.
October 2015
Physical Therapist Practice in the ICU
This study was funded by National Institutes
of Health grant R01NR011051.
DOI: 10.2522/ptj.20140417
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