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Vol. 30. Issue 4.
Pages 319-323 (July - August 2024)
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Vol. 30. Issue 4.
Pages 319-323 (July - August 2024)
Editorial
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Physiotherapists in intensive care units: Where are we?
Visits
1695
F. Ramalhoa,c, A. Oliveiraa,b,d, A. Machadoa,b, V. Azevedoe, M.R. Gonçalvesf, G. Ntoumenopoulosg, A. Marquesa,b,
Corresponding author
amarques@ua.pt

Corresponding author at: Respiratory Research and Rehabilitation Laboratory (Lab3R), School of Health Sciences (ESSUA) and Institute of Biomedicine (iBiMED), University of Aveiro, Agras do Crasto - Campus Universitário de Santiago, Edifício 30, 3810-193, Aveiro, Portugal.
a Lab3R – Respiratory Research and Rehabilitation Laboratory, School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal
b iBiMED – Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
c Hospital Professor Doutor Fernando Fonseca, Lisbon, Portugal
d School of Rehabilitation Sciences, McMaster University, Canada
e Centro Hospitalar Lisboa Ocidental - Egas Moniz Hospital - Polyvalent Intensive Care Unit, Alcoitão School of Health Sciences, Lisbon, Portugal
f Noninvasive Ventilatory Support Unit, Emergency and Intensive Care Medicine Department, Pulmonology Department, São João University Hospital. Faculty of Medicine, University of Porto, Portugal
g Department of Physiotherapy, St Vincent's Hospital, Sydney, Australia
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Table 1. Characteristics of physiotherapists working in Portuguese intensive care units (n=181) and of those working in intensive care units of public (n=129) and private (n=16) hospitals.
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The ever-increasing complexity of critically ill patients requires multidisciplinary teams in the intensive care units (ICU) with a wide range of skills and expertise.1 Physiotherapy is an integral part of this multidisciplinary approach and has shown to be safe, feasible and effective, contributing to improved outcomes,2–6 such as reduced respiratory infections, duration of mechanical ventilation, and risk of death by 30%.7

For these reasons, current national and international guidelines recommend the presence of a specialised physiotherapist for every five beds, seven days/week, ensuring 24-hour physiotherapy coverage.8,9 Despite these recommendations, information about the actual role, functions and time allocation of physiotherapists in ICU is limited, particularly in Portuguese ICU. The existing data originates from a single study conducted over two decades ago.10 This knowledge gap poses challenges in ICU decision-making, professional and guideline development, and may impact patient outcomes.

To grasp the current state of physiotherapy in Portuguese ICU, we conducted a cross-sectional online survey from November 2022 to January 2023, targeting all physiotherapists in adult ICUs across Portugal, covering the mainland, Azores and Madeira. Inclusion criteria involved physiotherapists actively working in an ICU on weekdays or weekends during the prior year, excluding those offering occasional support. Sixty-eight hospitals were contacted (52 public and 16 private), of which 16 (24%) reported not having physiotherapy in the ICU (Fig. 1). Considering the 52 hospitals with physiotherapy in the ICU, the response rate was 85%.

Fig. 1.

Distribution of Portuguese hospitals with intensive care units and physiotherapists.

(0.27MB).

The survey showed that 25% of Portuguese hospitals lack an ICU physiotherapist. Among those with physiotherapists, only 11% work exclusively in the ICU, with the majority (85%) operating on a rotational basis with other services or solely at weekends (Table 1). This scenario not only goes against the recommendations from both national and international guidelines,1,8,9 but also contrasts with the broader European situation, where 75% of ICUs report having at least one physiotherapist working exclusively.10

Table 1.

Characteristics of physiotherapists working in Portuguese intensive care units (n=181) and of those working in intensive care units of public (n=129) and private (n=16) hospitals.

  Total (n=181)  Public hospitals (n=129)  Private hospitals(n=16)  p-value 
Age, years  39.3±8.8  39.5±8.1  37.5±12.1  0.213Ѱ 
Sex        0.927£ 
Female  138(a) (76.2%)  96 (74.4%)  11 (73.3%)   
Male  42(a) (23.2%)  33 (25.6%)  4 (26.7%)   
Academic and professional training         
Undergraduate only  75(a) (41%)  47 (36.4%)  8 (50%)  0.409£ 
Post graduate specialisation  59(a) (33%)  44 (34.1%)  4 (25%)  0.409£ 
Master's degree  42(a) (23%)  34(26.4%)  4 (25%)  0.409£ 
Other specific training  114(a) (63%)  83 (64.3%)  10 (62.5%)  0.885£ 
Years of experiencenTS=146; nPH=129; nPrH=15         
Physiotherapist without working in ICU  15 [9-24]  16 [10-23]  11 [4-27]  0.253Ѱ 
Physiotherapist in ICU  6 [2-14]  7 [2-14]  4 [2-15]  0.491Ѱ 
ICU exclusivitynTS=144; nPH=124; nPrH=16        0.109£ 
Rotating with another service  67(a) (46.5%)  53 (42.7%)  12 (75%)   
Only at weekends  56(a) (38.9%)  52 (41.9%)  3 (18.8%)   
Exclusive work in ICU  16 (11.1%)  15 (12.1%)  1 (6.3%)   
Dedicated time to the ICU, hours/per monthnTS=119; nPH=104; nPrH=15  36.8±36.9  35.7±38  36±27.8  0.377 Ѱ 
Head of servicenTS=149; nPH=129; nPrH=16        <0.001£ 
Physiotherapist  52 (34.9%)  41 (31.8%)  11 (68.8%)   
Physician  94(a) (51.9%)  88 (68.2%)  4 (25%)   
Physiotherapy at weekendsnTS=145; nPH=125; nPrH=16        0.450£ 
Always  90(a) (62.1%)  77 (61.6%)  10 (62.5%)   
Exceptionally  33(a) (22.8%)  27 (21.6%)  5 (31.3%)   
Never  22 (15.2%)  21 (16.8%)  1 (6.3%)   
No physiotherapy at nightnTS=145; nPH=125; nPrH=16  143(a) (98.6%)  123 (98.4%)  16 (100%)  0.610£ 
Orientation program for new physiotherapistsnTS=145; nPH=125; nPrH=16  73(a) (49.7%)  68 (54.4%)  4 (25%)  0.027£ 
Early mobilisation teamnTS=144; nPH=124; nPrH=16  71(a) (49.3%)  62 (50%)  7 (43.8%)  0.638£ 

Legend: Continuous variables are presented as mean ± standard deviation or median [first quartile - third quartile] according to their distribution. Categorical variables were expressed as absolute frequency (%). Number of responses used in the analysis was indicated in front of the corresponding variable when complete cases were not available.

PH: Public Hospital; PrH: Private Hospital; nTS= number of responses used from the total sample; nPH= number of responses used from public hospitals; nPrH= number of responses used from private hospitals; for comparisons between groups, a Chi-squared test (£) or U-Mann-Whitney test (Ѱ) were used where appropriate.

(a)

not all answers reported the type of hospital. Statistically significant differences are in bold.

Contributing to the absence of ICU-exclusive physiotherapists is the fact that, in Portugal and other Mediterranean countries like Greece,11 physiotherapists working in hospitals often need to attend to patients from various settings, including in and outpatients, explaining the reported heterogeneous training of Portuguese ICU physiotherapists, such as training in women's health (12%) or musculoskeletal (31%).

Exclusive dedication to physiotherapy in Portuguese ICU is, therefore, scarce, but there is also limited physiotherapist presence during weekends and night shifts. Of the participating hospitals, only 23 (52%) consistently had physiotherapy services available on weekends. Despite the clear benefits for patients,7 families12 and health systems13,14 of having continuous physiotherapy ICU coverage 24/7, such as reducing the length of stay, mechanical ventilation support, pulmonary infection and mortality,7 European rates vary widely. Greece,11 Germany or Sweden10 lack overnight coverage, while others, like the United Kingdom, frequently have an overnight presence.10 The reason behind this range of national practices and the non-adherence to the same European guidelines remains unclear and undoubtedly requires further exploration to create conditions for healthcare institutions to adhere to the guidelines and improve the quality of their care.

In addition to the well-established benefits of ICU physiotherapy, increased awareness about physiotherapists’ roles and competencies is also needed to promote their continuous presence in ICU teams. In Portugal, our survey showed that physiotherapy assessments frequently include direct observation, discussion of clinical processes and the application of scales. Interventions include patient re-positioning, mobilisation, exercise, muscle strengthening and airway clearance techniques. These roles align with those reported in national surveys from other European countries.10,11,15 Moreover, physiotherapists in Portuguese ICU demonstrate a higher level of autonomy for technical aspects, such as tracheal aspiration or discussions with the medical team about extubation, compared to their counterparts in other European countries,10 making them a valuable asset in providing quality care and contributing to positive patients’ outcomes in ICU.1,14

Early mobilisation is a critical role of physiotherapists in ICU teams, providing important benefits for hospitals and patients,5,16–18 such as decreased length of stay and morbidity.7,19 Physiotherapists should, therefore, be integrated into interdisciplinary mobility teams, also including physicians, nurses and occupational therapists.16,20 In Portugal, 50% of these physiotherapists are not integrated into interdisciplinary teams and often lack established multidisciplinary protocols, hindering the implementation of this crucial intervention for patients’ rehabilitation. Lack of equipment and training are among the most reported reasons not to implement early mobilisation, as well as other evidence-based assessments/interventions, such as lung and muscle ultrasonography, peak cough expiratory flow measure, maximal inspiratory pressure, electronic cycle ergometer and inspiratory muscle training, both in Portugal (data from our survey) and in various countries around the world, including Zimbabwe,21 Sri Lanka22 and Canada.23

Despite facing numerous challenges, physiotherapists in Portugal are a motivated yet scarce workforce. Efforts to enhance physiotherapy practice in Portuguese ICU should focus on ensuring the presence of physiotherapists in ICU 7-days/week, creating and implementing early mobilisation teams, increasing the availability of recommended equipment, and increasing collaborations with universities to expand physiotherapists’ training and specialisation. International action to update the status of physiotherapy in ICU worldwide is much-needed to inform and foster physiotherapy professional development and enhance the overall quality of ICU care.

Less-explored areas that would also be interesting to investigate include unpaid/family carers support and involvement, delirium prevention and control approaches, interdisciplinary meetings, virtual reality, post-discharge follow-up, or ICU protocols.

Before we wrap up this editorial, we would like to share with the readers two emerging areas in critical patient rehabilitation: family involvement and virtual reality. Studies have indicated that involving families in physiotherapy-related tasks for critically ill patients can enhance the recovery experience.24 Is it time to start reconnecting patients with families early, and adapt our physiotherapy approach accordingly? Simultaneously, innovative studies using virtual reality have demonstrated that a combined rehabilitation strategy can offer advantages in maximising functional recovery and mitigating disability.25 How will intensive care physiotherapists respond to these advancements? We invite all of those dedicated to advancing physiotherapy in ICU to embrace this exciting new era ahead of us, full of clinical and research opportunities, aimed at ultimately enhancing the well-being and quality of life of patients and families.

Ethics approval and consent to participate

The study was approved by two Ethics Committees (UA 41-CED/2022 06/07/2022; HFF 63/2022 19/08/2022). Informed consents were obtained from all participants before any data collection.

Consent for publication

Not applicable.

Availability of data and material

Detailed description of the methodology and results of the study may be provided upon request.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors contribution

FR, AM, AO and AFM conceived and designed the work. AM, AO and AFM contributed to and verified the analytical methods. GN contributed to the survey conception. FR, VA and MG contributed to the survey's dissemination. FR performed data collection, data analysis and drafted the manuscript. AM and AO supervised the findings of this work. All authors critically revised the manuscript, ensured the accuracy and integrity of the work, approved the final version to be published, and agreed to be accountable for all aspects of the work.

Acknowledgments

The authors wish to thank all study participants and physiotherapy coordinators for their collaboration.

References
[1]
R Gosselink, J Bott, M Johnson, et al.
Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients.
Intensive Care Med, 34 (2008), pp. 1188-1199
[2]
R Dubb, P Nydahl, C Hermes, et al.
Barriers and strategies for early mobilization of patients in intensive care units.
Ann Am Thorac Soc, 13 (2016), pp. 724-730
[3]
J Sommers, RH Engelbert, D Dettling-Ihnenfeldt, et al.
Physiotherapy in the intensive care unit: an evidence-based, expert driven, practical statement and rehabilitation recommendations.
Clin Rehabil, 29 (2015), pp. 1051-1063
[4]
TD Girard, W Alhazzani, JP Kress, et al.
An Official American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: liberation from mechanical ventilation in critically ill adults rehabilitation protocols, ventilator liberation protocols, and cuff leak tests.
Am J Respir Crit Care Med, 195 (2017), pp. 120-133
[5]
R Gosselink, B Clerckx, C Robbets, et al.
Physiotherapy in the intensive care unit.
Netherlands J Crit Care, 15 (2011), pp. 66-75
[6]
CA Linke, LB Chapman, LJ Berger, et al.
Early mobilization in the ICU: a collaborative, integrated approach.
Crit Care Explor, 2 (2020), pp. e0090
[7]
AAM Castro, SR Calil, SA Freitas, et al.
Chest physiotherapy effectiveness to reduce hospitalization and mechanical ventilation length of stay, pulmonary infection rate and mortality in ICU patients.
Respir Med, 107 (2013), pp. 68-74
[8]
A Valentin, P Ferdinande, ESICM Working Group on Quality Improvement.
Recommendations on basic requirements for intensive care units: structural and organizational aspects.
Intensive Care Med, 37 (2011), pp. 1575-1587
[9]
D Nuñez, J Gouveia, J Sousa, et al.
Atualização da Rede Nacional de Especialidade Hospitalar e de Referenciação - Medicina Intensiva.
[10]
M Norrenberg, J-L. Vincent.
A profile of European intensive care unit physiotherapists.
Intensive Care Med, 26 (2000), pp. 988-994
[11]
E Grammatopoulou, TN Charmpas, EG Strati, et al.
The scope of physiotherapy services provided in public ICUs in Greece: a pilot study.
Physiother Theory Pract, 33 (2017), pp. 138-146
[12]
GA Colbenson, A Johnson, ME. Wilson.
Post-intensive care syndrome: impact, prevention, and management.
Breathe, 15 (2019), pp. 98-101
[13]
BP Rotta, JMD Silva, C Fu, et al.
Relationship between availability of physiotherapy services and ICU costs.
J Bras Pneumol, 44 (2018), pp. 184-189
[14]
S Nava, N. Ambrosino.
Rehabilitation in the ICU: the European phoenix.
Intensive Care Med, 26 (2000), pp. 841-844
[15]
GW Ou, MJH Ng, CLW Ng, et al.
Physiotherapy practice pattern in the adult intensive care units of Singapore – a multi-centre survey.
Proc. Singapore Health., 31 (2022),
[16]
CE Hickmann, D Castanares-Zapatero, E Bialais, et al.
Teamwork enables high level of early mobilization in critically ill patients.
Ann Intensive Care, 6 (2016), pp. 1-11
[17]
JK Lang, MS Paykel, KJ Haines, et al.
Clinical practice guidelines for early mobilization in the ICU: a systematic review.
Crit Care Med, 48 (2020), pp. e1121-e1128
[18]
CL. Hodgson, K Stiller, DM Needham, et al.
Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults.
[19]
L Zhang, W Hu, Z Cai, et al.
Early mobilization of critically ill patients in the intensive care unit: a systematic review and meta-analysis.
[20]
WD Schweickert, MC Pohlman, AS Pohlman, et al.
Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial.
Lancet, 30 (2009), pp. 1874-1882
[21]
C Tadyanemhandu, S. Manie.
Profile of patients and physiotherapy patterns in intensive care units in public hospitals in Zimbabwe: a descriptive cross-sectional study.
BMC Anesthesiol, 15 (2015), pp. 136
[22]
PC Sigera, TM Tunpattu, TP Jayashantha, et al.
National profile of physical therapists in critical care units of Sri Lanka: lower middle-income country.
Phys Ther, 96 (2016), pp. 933-939
[23]
KK Koo, K Choong, DJ Cook, et al.
Early mobilization of critically ill adults: a survey of knowledge, perceptions and practices of Canadian physicians and physiotherapists.
CMAJ Open, 4 (2016), pp. e448-e454
[24]
L van Delft, K Valkenet, A Slooter, et al.
Perceptions and ideas of critically ill patients, their family and staff members regarding family participation in the physiotherapy-related care of critically ill patients: a qualitative study.
Physiother Theory Pract, 38 (2022), pp. 2856-2873
[25]
D Kanschik, RR Bruno, G Wolff, et al.
Virtual and augmented reality in intensive care medicine: a systematic review.
Ann Intensive Care, 13 (2023), pp. 81
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