Guideline Update: Early mobilization advised for all ICU patients
But how realistic is its implementation?
In a March 2025 guideline update, the major U.S. critical care society advised that all critically ill patients should receive “enhanced mobilization” or rehabilitation, over and above usual physical therapy.
As only a minority of hospitals even provide ordinary physical therapy to mechanically ventilated patients on a routine basis, the advisement is largely symbolic or aspirational.
“Enhanced” rehabilitation can include such activities as helping patients stand at bedside or walk around the ICU on mechanical ventilation, or simpler interventions such as in-bed cycling (ergometry).
The committee relied on a large body of evidence including over 50 randomized controlled trials, most of which were performed in Australasia, the US, Europe, and Canada.
What did the data show?
The strongest finding was for the prevention of ICU-acquired weakness.
In the meta-analysis of 14 trials testing weakness as an outcome (n=1,427), enhanced mobilization significantly reduced ICU-acquired weakness with a relative risk of 0.77, with a 95% confidence interval of 0.64 to 0.93.
Limiting that meta-analysis to include only multicenter trials in high-income countries, or to all trials in high-income nations, revealed a statistically nonsignificant trend toward reduction of ICU-acquired weakness:
ICU-Acquired Weakness (Multicenter RCTs in High-Income Countries Only, n~555):
RR 0.81, 95% CI 0.59 to 1.13.
ICU-Acquired Weakness (All RCTs in High-Income Countries, n~821):
RR 0.90, 95% CI 0.74 to 1.10.
~One Day Less on Mechanical Ventilation:
Enhanced mobilization seemed to reduce the duration of mechanical ventilation:
Duration of Mechanical Ventilation (n~4,700): Minus 1.1 days, 95% CI minus 1.7 to minus 0.5 days.
No Mortality Benefit:
Enhanced rehab had no apparent influence on mortality, however, with pooled relative risks very close to 1.0:
ICU Mortality (n~4,730): RR 0.98, 95% CI 0.85 to 1.13.
Hospital Mortality (n~2,930): RR 1.01, CI 0.84 to 1.22.
Mortality at Longest Follow-Up (n~6,730): RR 1.01, CI 0.93 to 1.10.
Improved Quality of Life and Functional Outcomes
Quality of life and functional outcomes were consistently improved in patients randomized to enhanced rehabilitation and early mobilization.
No Consistent Serious Safety Signals
Arrhythmias like atrial fibrillation were significantly more common in patients randomized to enhanced physical therapy, but resolved without generating any concerning signal for an increase in cardiac events.
Unplanned extubations, line dislodgements, and hypotension were not significantly increased in the enhanced mobilization groups.
Who Benefits? Patient Selection Remains A Challenge in Implementation
Most of the randomized trials enrolled only patients considered likely to benefit from rehabilitation. Generally, this meant enrolling those with good pre-hospital function and excluding patients with significant disabilities at baseline.
In trials testing less carefully selected cohorts of patients, enhanced rehabilitation has not shown consistent benefits. The most likely conclusion is that patients with preexisting weakness and frailty (as a group) do not benefit from intensive physical therapy in any measurable way.
This creates a conundrum for hospitals, because such patients comprise a large proportion of the critically ill. Restricting enhanced PT to higher-functioning patients (or denying it to lower-functioning patients) creates a reputational risk, especially if there are other correlated demographic differences (exposing the institution to the appearance of “rationing” or “inequity”, e.g.).
But providing it to all ICU patients would produce significant expenses without benefiting most recipients. With benefits included, experienced physical therapists cost a hospital around $125,000 per year, per therapist. Each might realistically see four to six vented (or otherwise complex) patients per day.
As the guideline authors noted, “resource limitations can be a significant barrier to implementing such a program.”
Hiring therapists is only one piece of a serious enhanced rehab program in an ICU. Additional training and equipment (lifts, etc.) must also be accompanied by culture shifts, buy-in and a comfort level among nurses and physicians.
Resources and Strategies
Dubb et al identified dozens of such barriers and also synthesized dozens of potential strategies and solutions in a systematic review (Annals ATS 2016).
Johns Hopkins’s AMP Adult ICU Early Rehabilitation program is an evidence-based, multidisciplinary intervention that includes an out-of-the-box training program for physical therapists. You can request their toolkit here.
Hopkins also runs an annual conference for therapists interested in ICU early mobility: details here.
Collected resources are at ICUrehabnetwork.com.
Minnesota Health described their protocol here.
PulmCCM has no affiliation with and does not endorse any of these links or institutions.
Conclusion: Little Immediate Practical Impact
Although many U.S. hospitals profess to already provide early mobilization to patients in their ICUs, in practice physical therapy is delivered sparingly if at all to most vented patients.
This guideline update may spur some systems to bolster their efforts toward enhanced rehabilitation and early mobilization.
It might encourage other centers providing “standard” physical therapy (i.e., not much) in their ICUs to do more, even without a formally “enhanced” program.
Numerous resources are available to help motivated leaders start the journey of providing early mobilization and enhanced rehabilitation at their centers.
But such systems-level implementations are beyond the purview of practicing clinicians, who will continue to check the box in the EMR to request physical therapy and hope for the best.