Factors influencing physical activity and rehabilitation in survivors of critical illness: a systematic review of quantitative and qualitative studies

Abstract

PurposeTo identify, evaluate and synthesise studies examining the barriers and enablers for survivors of critical illness to participate in physical activity in the ICU and post-ICU settings from the perspective of patients, caregivers and healthcare providers. Methods
Systematic review of articles using five electronic databases: MEDLINE, CINAHL, EMBASE, Cochrane Library, Scopus. Quantitative and qualitative studies that were published in English in a peer-reviewed journal and assessed barriers or enablers for survivors of critical illness to perform physical activity were included. Prospero ID: CRD42016035454. ResultsEighty-nine papers were included. Five major themes and 28 sub-themes were identified, encompassing: (1) patient physical and psychological capability to perform physical activity, including delirium, sedation, illness severity, comorbidities, weakness, anxiety, confidence and motivation; (2) safety influences, including physiological stability and concern for lines, e.g. risk of dislodgement; (3) culture and team influences, including leadership, interprofessional communication, administrative buy-in, clinician expertise and knowledge; (4) motivation and beliefs regarding the benefits/risks; and (5) environmental influences, including funding, access to rehabilitation programs, staffing and equipment. Conclusions
The main barriers identified were patient physical and psychological capability to perform physical activity, safety concerns, lack of leadership and ICU culture of mobility, lack of interprofessional communication, expertise and knowledge, and lack of staffing/equipment and funding to provide rehabilitation programs. Barriers and enablers are multidimensional and span diverse factors. The majority of these barriers are modifiable and can be targeted in future clinical practice.

Full text

Intensive Care Med
DOI 10.1007/s00134-017-4685-4
SYSTEMATIC REVIEW
Factors inuencing physical activity
andrehabilitation insurvivors ofcritical
illness: a systematic review ofquantitative
andqualitative studies
Selina M. Parry1*, Laura D. Knight2, Bronwen Connolly3,4,5, Claire Baldwin6, Zudin Puthucheary4,7, Peter Morris9,
Jessica Mortimore3,5, Nicholas Hart3,5,8, Linda Denehy1 and Catherine L. Granger1,2,10
© 2017 Springer-Verlag Berlin Heidelberg and ESICM
Abstract
Purpose: To identify, evaluate and synthesise studies examining the barriers and enablers for survivors of critical ill-
ness to participate in physical activity in the ICU and post-ICU settings from the perspective of patients, caregivers and
healthcare providers.
Methods: Systematic review of articles using five electronic databases: MEDLINE, CINAHL, EMBASE, Cochrane
Library, Scopus. Quantitative and qualitative studies that were published in English in a peer-reviewed journal and
assessed barriers or enablers for survivors of critical illness to perform physical activity were included. Prospero ID:
CRD42016035454.
Results: Eighty-nine papers were included. Five major themes and 28 sub-themes were identified, encompassing: (1)
patient physical and psychological capability to perform physical activity, including delirium, sedation, illness severity,
comorbidities, weakness, anxiety, confidence and motivation; (2) safety influences, including physiological stability
and concern for lines, e.g. risk of dislodgement; (3) culture and team influences, including leadership, interprofessional
communication, administrative buy-in, clinician expertise and knowledge; (4) motivation and beliefs regarding the
benefits/risks; and (5) environmental influences, including funding, access to rehabilitation programs, staffing and
equipment.
Conclusions: The main barriers identified were patient physical and psychological capability to perform physi-
cal activity, safety concerns, lack of leadership and ICU culture of mobility, lack of interprofessional communication,
expertise and knowledge, and lack of staffing/equipment and funding to provide rehabilitation programs. Barriers
and enablers are multidimensional and span diverse factors. The majority of these barriers are modifiable and can be
targeted in future clinical practice.
Keywords: Critical care, Rehabilitation, Physical therapy, Review, Behaviour change, Physical activity
*Correspondence: selina.parry@unimelb.edu.au
1 Department of Physiotherapy, School of Health Sciences, The University
of Melbourne, Level 7 Alan Gilbert Building, Parkville, Melbourne, VIC
3010, Australia
Full author information is available at the end of the article
Take-home message: This systematic review has identified the barriers
and enablers for performance of physical activity by survivors of critical
illness. Barriers and enablers are multidimensional and span diverse
factors. The majority of these barriers are modifiable and can be targeted
in future clinical practice.

Introduction
Survivorship following critical illness results in signifi-
cant morbidity in terms of long-lasting post-ICU physi-
cal, cognitive and mental health morbidity [1]. Muscle
weakness and impaired physical functioning are key limi-
tations, which impact on a patient’s return to work and
quality of life. Exercise and physical activity (as an inter-
vention) is safe, feasible and potentially efficacious in sur-
vivors of critical illness at improving patient outcomes
especially when applied early in the ICU [2, 3]. Physical
activity (PA) is defined as “bodily movement produced
by skeletal muscles that results in energy expenditure”
[4]. It encompasses mobilisation, exercise training, reha-
bilitation and general activities of daily living. Despite
supportive practice guidelines [5, 6], international point
prevalence studies have demonstrated that low PA lev-
els exist in the ICU [7–9]. A current gap exists between
the perceived need and desire to enhance PA levels and
actual implementation of PA interventions into routine
care.
Recent publications have profiled barriers to early
mobilisation specifically in the ICU setting, existing
both at the patient and hospital level [10, 11]. However, a
broader understanding of the specific barriers is needed.
Such data are highly relevant to inform changes in clini-
cal practice, service delivery, policy and research aiming
to enhance PA levels and survivorship outcomes. e
aim of this review is to evaluate studies examining the
barriers and enablers for survivors of critical illness to
participate in PA in the ICU and post-ICU setting from
the perspective of patients, caregivers and healthcare
providers (HCPs). We hypothesize that the barriers and
enablers will be diverse and multifactorial at the patient,
healthcare provider and institutional level. is research
was presented at the European Society of Intensive Care
Medicine Conference in 2016 with associated published
abstract [12].
Methods
Guidelines andprotocol registration
The Preferred Reporting Items for Systematic
Reviews and Meta-Analyses guidelines [13] and
Enhanced Transparency of Reporting the Synthesis
of Qualitative Research framework [14] guided this
review. The protocol was registered on PROSPERO
(CRD42016035454).
Eligibility criteria
Studies assessing barriers or enablers to individuals
with critical illness participating in PA interventions
were included (and could be from the perspective of the
patient, caregiver or HCP) (Table1).
Information sources andsearch
Five electronic databases (Fig.1) were searched by one
reviewer (SP) using a pre-planned systematic compre-
hensive and reproducible search strategy (ETable 1) to
identify all published studies against defined eligibility
criteria. Databases were accessed via e University of
Melbourne and the last search was run on 26 December
2016.
Study selection
Eligibility assessment was performed in a standardised
manner. Two independent reviewers (SP, LK) screened
titles, abstracts and full-text articles (Fig. 1) against
defined eligibility criteria (Table 1). Disagreement was
resolved by consensus with a third reviewer (CG) when
needed.
Data collection process anddata items
Data extraction was independently performed by two
authors (BC, JM) for quantitative studies using bespoke
data collection forms, and cross-checked by a sec-
ond (CB, LK). Data items included author details, year
Table 1 Eligibility criteria forinclusion ofprimary studies inthe systematic review
ADLs activities of daily living, HCPs healthcare providers, ICU intensive care unit, PA physical activity, RCT randomized controlled trial
Characteristics Inclusion Exclusion
Study design Quantitative including RCTs, pseudo-RCTs, cohort studies, case–control
studies, case series, cross-sectional studies; or
Qualitative
No original participant data (such as editorials, review
papers or clinical guidelines)
Conference abstracts
Participants Adults admitted to ICU; or
Caregivers of patients admitted to ICU; or
HCPs working with patients in or post ICU
Studies with less than five participants
Specialized patient populations such as neurological,
trauma, transplant
Exposure Participation in PA defined as “any bodily movement produced by skeletal
muscles that results in energy expenditure” [1] by individuals with critical
illness or survivors of critical illness. Includes general PA, mobilisation,
exercise training, rehabilitation and ADLs
Passive range of motion, muscle stimulation
Outcomes Barriers and enablers to PA
Publication Published in English
No publication date restriction Not published in a peer-reviewed journal

published, aims, study design, methods, participant char-
acteristics and results (including barriers and enablers to
PA). For qualitative studies all text under the headings
‘results/conclusions’ was extracted manually by two inde-
pendent reviewers (SP, CG) and cross-checked.
Risk ofbias inindividual studies
Independent reviewers (SP, CG) assessed the quality of
the quantitative evidence using the Oxford Centre for
Evidence-based Medicine scale for rating of individual
studies. Qualitative studies were assessed using the
consolidated criteria for reporting qualitative research
(COREQ) checklist [15]. Results of studies were given the
same weight regardless of their assessed risk of bias.
Synthesis ofresults
A meta-analysis was not possible because of the hetero-
geneity in study design and measures. Quantitative data
on barriers and enablers to PA were synthesised using
thematic synthesis [16]. Two independent reviewers (SP,
CG) performed line-by-line coding of text from the quali-
tative studies, and similar concepts were grouped and
new codes developed when necessary. Free codes were
organised into descriptive major themes and sub-themes
using an inductive approach [16]. Discrepancies were dis-
cussed between reviewers and consensus was achieved
on all occasions. A third reviewer (CB) cross-checked the
data to ensure the relevant data was accurately captured
and integrated into appropriate themes (CB).
Records idenfied through database
searching: MEDLINE (1950-2016),
CINAHL (1982-2016), EMBASE (1980-
2016), Scopus (2004-2016), Cochrane
Library (2016) (n=4, 122)
Addional records idenfied (n=55)
•cross referenced reports (n =55)
•personal files (n=0)
Records for screening of tle, and
abstract, aer duplicates and not
relevant removed(SP, LK)(n=849)
(n=849)
Records excluded (n=705)
•Conference abstract (n=167)
•Review, editorial, narrave (n=162)
•Not rehabilitaon (n=149)
•Special populaon (n=69)
•Not ICU (n=60)
•Not barriers or enablers (n=34)
•Other reason (n=23)
•Not published in English (n=13)
•Neonatal (n=13)
•Protocol (n=7) or case report (n=8)
Full-text arcles assessed for eligibility
by independent reviewers (SP, LK)
(n=144)
Records excluded (n=55)
•Not rehabilitaon (n=21)
•Not barriers or enablers (n=14)
•Review, editorial or narrave (n=6)
•Special populaon (n=4)
•Paediatric (n=4)
•Not ICU (n=2)
•Protocol (n=2)
•< 5 parcipants (n=2)
Studies included in synthesis (n=89)
Included
Eligibility Idenficaon
Screening
Fig. 1 PRISMA flow diagram of study selection process [13]. CINAHL Cumulative Index to Nursing and Allied Health Literature, EMBASE the Excerpta
Medica Database

Results
Study selection andcharacteristics
A total of 4122 studies were screened resulting in the
final inclusion of 89 papers (ETable4), including 77 quan-
titative (87%) and 12 qualitative (13%) studies (ETable4).
Studies were conducted in 11 different countries (ETa-
ble2); the most common were USA (n=54, 61%); Aus-
tralia (n=13, 15%) and UK (n=10, 11%). Overall, 17,547
patients, 4425 HCPs and 56 caregivers were included in
this review. e majority of papers (93%, n=83) were
focused on the ICU setting alone, with only 7% focused
on assessing barriers or enablers in the post-ICU setting.
Over half (55%) of included studies were published since
2014.
Quality assessment ofincluded studies
e majority of included quantitative studies were
either case series with or without intervention or cross-
sectional study (n=48/77, 62%) (ETable4). Qualitative
studies scored poorly for lack of reporting of the inter-
viewer’s characteristics and relationship between inter-
viewers and participants within Domain 1 ‘Team and
Reflexivity’. e median [interquartile] score for qualita-
tive studies was 21 [11–22], ETable5.
Synthesis ofresults
Five major themes and 28 sub-themes for barriers and
enablers to PA were identified across the 89 papers
included (Fig.2, ETable3). Quotes from primary qualita-
tive studies are provided to reflect themes. Each theme
will now be discussed descriptively. e relevant sub-
themes for each theme are summarised in ETable 3;
please refer to this for further detail.
Theme 1: patient physical andpsychological inuences
ere was conflicting evidence for the association
between illness severity, age, weight and presence of
comorbidities and receipt of rehabilitation in the ICU
(ETable3). Symptoms of pain, fatigue and weakness were
identified as barriers to PA [8, 9, 17–21]. Fatigue and
patient refusal were common reasons for early cessation
or lack of PA [17, 18, 22–26] and weakness was a com-
mon barrier to mobilisation [8, 9, 20].
Sedation was a frequently identified barrier in the ICU
[8, 9, 17, 19–21, 23–25, 27–41]. Other barriers included
agitation [8, 20, 23, 25, 42], delirium [18, 21, 33, 34, 37]
and patient alertness [8, 26, 27, 36, 42]. Studies found that
sedation, delirium and alertness influenced the patient’s
ability to engage in PA [7, 43]. Early PA was facilitated
when combined with good sedation and delirium practice
and in some studies this occurred as part of the awaken-
ing and breathing coordination, delirium monitoring and
management, early mobility (ABCDE) bundle [21, 34,
44–47]. Adequate sleep was recognised as a facilitator for
patient engagement in PA [48]. Physiotherapists identi-
fied patient anxiety, fear, lack of motivation, confidence,
and patient knowledge about ICU-acquired weakness
(ICUAW) as factors impeding adherence to interventions
[43]. Gaining patient trust, setting goals with the patient,
addressing anxiety concerns and involving caregivers
were recognised as enablers [41].
Theme 2: safety inuences
Haemodynamic and respiratory physiological stability
were significant influences [8, 9, 17–22, 24, 25, 27, 33,
39, 42, 49–52]. Medical contraindications, complications
and medical procedures/investigations were barriers and
contributed to missed therapy sessions, particularly in
the ICU [9, 17, 18, 24, 49]. e development of physiolog-
ical stability guidelines for rehabilitation was an enabler
[21, 33].
Safety concerns regarding lines were perceived as a
barrier to mobilisation [19, 21, 24, 27, 31, 33, 53], in par-
ticular the presence of pulmonary artery catheters [20,
53], femoral lines [18, 20, 42] or haemodialysis [7, 17, 18,
30, 51].
However, several studies specifically reported the safety
of PA with lines in situ and found no adverse events
Ancipated Risks / Benefits (HCPs)
Experienced Benefits / Risks
(Paents, caregivers, HCPs)
Admission Dx, severity of illness
Age / Comorbidies
Symptoms, Muscle strength
Sedaon, delirium and cooperaon
Neurological impairment
Physiological stability
Presence of lines / aachments
Mobilizing MV with ETT
Fear of injury to Paents,
caregiver, and HCPs
Workplace culture
Communicaon
Leadership Presence
Experse and Training
Role Clarity and Accountability
Access to rehab programs
Hospital admin buy-in
Locaon of paents
Equipment, Staffing
Compeng Priories
Mobility protocols / teams
QI projects
Movaons and Beliefs
Paent Physical &
Psychological influences
Safety Influences
Clinicianand Te am
Influences
Environmental Influences
Fig. 2 Summary of findings—themes influencing delivery of physical
activity in patients with critical illness. This figure highlights the five
themes and 28 sub-themes that were identified in this systematic
review. admin administrative, Dx diagnosis, ETT endotracheal tube,
HCPs healthcare providers, QI quality improvement, MV mechanical
ventilation, rehab rehabilitation

[54–58]. In one study physiotherapists and nursing staff
identified unnecessary lines and poor choice of line loca-
tion as barriers [41]. Planning to ensure device and line
securement was an identified enabler [21].
“e position of certain lines is frustrating, for exam-
ple when the vascaths have been inserted femorally
and you are ready to start them sitting, its just basic
planning.” [41]
Presence of an endotracheal tube (ETT) was a com-
mon barrier to mobilisation [7, 17, 20, 24]. Commonly
reported barriers to mobilising mechanically ventilated
(MV) patients included time required, concerns for air-
way dislodgement, risk of physiological instability, con-
comitant sedation and delirium [9, 36, 42, 52]. Concern
for patient [21, 22, 27, 33, 44, 45, 52, 59], staff [37] and
caregiver [44] safety was a consideration; and both nurses
and physiotherapists noted concern for their own safety
(risk of musculoskeletal injury) was a barrier to out-of-
bed activities [37].
Theme 3: culture andteam inuences
Barriers to PA included cultural/traditional practices
[33, 41, 59], staff attitudes [19], resistance to change
[34], staff morale [60] and lack of interprofessional
respect [60]. Factors which facilitated culture change to
enable increased PA included need for clinician belief
in the importance of rehabilitation and commitment to
changing practice; team-building meetings; shared per-
formance data emphasising evidence and safety; active
multidisciplinary collaboration and training [22, 45, 46,
48, 59, 60]. e inclusion of visible goal targets posi-
tively influenced mobilisation levels [46]. Staff were also
motivated by seeing patients mobilising and challenging
themselves [61]. e need to overcome family percep-
tions that patients were too sick for rehabilitation was
also identified as a potential enabler [59].
“If you get buy-in from all of the different disciplines,
its definitely easy. If you’re a rehab team who wants
to do this and you don’t have buy-in by your nurses
and physicians and respiratory, it’s not gonna hap-
pen.” [45]
Lack of interprofessional communication [41, 60, 62]
and coordination [25] were barriers and the reverse was
an enabler [34, 45, 59]. Enabling strategies included daily
ward rounds to discuss mobility [19, 44, 62], round-
ing checklists [60], team meetings [45], documented PA
goals [26, 41, 44], prompts and continuous feedback on
outcomes to the team [19, 34, 60, 61]. Communication
difficulties with ventilated patients led to frustration,
anxiety and poor adherence from the patient in relation
to engagement in PA [43].
“Communication and teamwork are probably the
biggest things.” [45]
Absence of leadership and champions of PA was a bar-
rier [21, 25] and designation of an overall leader and dis-
cipline champions was an enabler [21, 27, 33, 34, 45, 59,
60, 62].
“You need…strong advocates or champions in multi-
ple disciplines. I think having a champion—someone
who is really pushing it through, pushing it forward
especially on the physician side of things—makes a
big difference.” [45]
Role clarity and accountability were highlighted as
enablers, and lack of role delineation was a barrier to PA
[25, 41, 60, 61]. All staff believed mobility could not be
carried out by one discipline and the importance of the
MDT and role clarification was highly emphasised [33,
45, 61]. Physiotherapists were identified as instrumen-
tal members of this team [59]. Lack of knowledge and
training was a barrier across the multidisciplinary team
[19, 21, 22, 33, 34, 40, 41, 60, 62] and enablers included
education about the benefits of PA, addressing safety
concerns, site visits to successful programs and bench-
marking against other programs [21, 33, 41, 45, 46,
59–63].
Theme 4: motivation andbeliefs aboutphysical activity—
from patients, family andHCPs
Patients reported experiencing a number of positive
outcomes associated with PA. ese included improved
physical and psychological outcomes, reduced boredom
and isolation, and expressed enjoyment and satisfac-
tion in participating in PA programs [64, 65] all of which
were seen as enablers. Patients who underwent inpatient
PA programs wanted to continue post discharge, as they
believed it was an important part of their recovery [66].
Patients reported feeling cared about and supported by
staff and an increased ability to be self-reliant as a result
of participating in a supervised outpatient PA program
[64].
“A sense of achievement…every time you went…” [64]
However those exposed to an outpatient pulmonary
rehabilitation model felt it was not specific to their needs
as survivors of critical illness [67].
Caregivers felt that PA was extremely necessary and
beneficial and rated the necessity of physiotherapy higher
than patients did themselves [68]. However, they under-
estimated the enjoyment and overestimated the level of
difficulty of PA in the ICU as reported by patients [68].
Caregivers also perceived PA to be less beneficial in indi-
viduals who had been MV for more than 2 weeks, but
caregivers did not want less therapy to be provided [68].

Healthcare providers expected or had experienced pos-
itive clinical outcomes from their patients being active
[43, 45, 52, 53]. ese included improved physical and
psychological outcomes [43, 45, 52, 53]; reduced delirium
and improved sleep [45] and both reduced MV duration
and hospital and ICU length of stay [45, 52]. Consistently
across studies there was an overwhelming belief by HCPs
that increased PA was beneficial [26, 43, 45, 52, 53]. Staff
satisfaction due to feeling responsible for improving
patient outcomes with PA was an enabler [45].
“Physical therapy and occupational therapy have
shown that it shortened length of stay. It has helped
get patients off the ventilator more quickly, even get
them out of the ICU more quickly…” [45]
“To see those small improvements in a patient cre-
ates a lot of job satisfaction…a rewarding feeling.”
[45]
In some studies HCPs reported the perception that
there was limited evidence and importance to justify
increased PA [33, 40, 46]. Two studies also reported staff
scepticism and lack of awareness of longer-term impact
of critical illness [33, 46]. ere were conflicting views on
the benefits of PA in individuals who were MV, in par-
ticular the role of mobilisation whilst MV with an ETT,
with concerns that the risks outweighed potential ben-
efits for this subgroup [37, 52, 62].
Theme 5: environmental inuences
In the ICU setting lack off, or presence of, automatic
referral for physiotherapy was a barrier or enabler in
some countries [19, 22, 25, 33, 37, 40, 41, 59, 69]. e
importance of managerial support and funding for staff
resources and to support protocol change was high-
lighted [41, 45, 46, 70].
“If the hospital doesn’t buy the idea that mobilisa-
tion in the ICU is useful, then we won’t be able to do
it.” [45]
e type of ICU the patient was in (i.e. respiratory
versus medical, trauma; proactive mobility unit) was
identified as an enabler for some patient groups in some
studies [30, 46]. In different units this may be reflective
of the culture; significant factors which were in favour
of out-of-bed PA included large volume ICUs, academic
and presence of advanced care providers in one study
[36], but favoured community providers in another study
[71]. Limited or increased access to PA equipment and/
or other resources was identified as a barrier [17, 19, 21,
22, 24, 26, 33, 34, 40, 44, 60] and enabler [21, 33], respec-
tively. It has also been reported that available equipment
was not associated with out-of-bed activities [27] and
that minimum (rather than specialised) equipment is suf-
ficient [45].
“You need a certain amount of equipment, basic
equipment…fundamental resources. You don’t need
bells and whistles.” [45]
Time and competing priorities were raised frequently
as barriers and often led to lower prioritisation compared
to other daily care needs, particularly in the ICU setting
[8, 17–19, 23, 25, 27, 29, 31, 37, 40–42, 44, 49, 72–74].
e presence of a mobility protocol and/or mobility
teams strongly facilitated PA [9, 22, 37, 39, 44, 73, 74]
and lack of clear recommendations was a key barrier [73,
74]. In addition the implementation of quality improve-
ment projects to develop/implement a mobility program
or protocol was an enabler to PA in a number of studies
across different settings internationally [19, 21, 25, 31, 33,
34, 60–62, 69, 75–78].
Lack of funding was a significant barrier particularly for
outpatient PA programs [26, 46, 70]. ere was a strong
message from patients for the wish to continue rehabili-
tation after discharge home, and delay to receive rehabili-
tation was frustrating [64, 66]. Other patients reported
severe challenges in accessing services [64, 79]. Patients
who did access PA programs after hospital discharge
responded positively to bright and cheerful environ-
ments, use of music, and access to clinicians knowledge-
able on ICU-specific issues [65]. Preference for group
exercise was seen, albeit in small patient numbers [64].
“It was something else that I had to contend with on
top of trying to get better.” [64]
“I felt there was about a two week delay for his reha-
bilitation to start. And the reason I’m emphasizing
on the delay is because two weeks after an ICU stay
for a survivor is a long, long time.” [66]
Lack of dedicated staffing (especially at weekends),
workload burden and willingness were barriers, and
these were a consistent issue in the ICU and post-ICU
settings [19, 21, 22, 26, 29, 31–33, 37, 40, 44, 45, 59, 60,
62, 70]. Presence of a dedicated rehabilitation team was
one of the most important enabling factors identified [31,
41, 45, 60].
“In the end sometimes they’re just left in bed because
I can’t get a second pair of hands.” [41]
In the absence of increased funding or staffing, two
studies reported the possibility of achieving improved
patient outcomes through restructuring of roles, respon-
sibilities and care pathways [25, 46]. However it is not

clear whether staffing levels are associated with mobil-
ity activities, with conflicting results from two studies [7,
27].
Discussion
In the largest body of research synthesised to date on this
topic we have identified that the barriers to PA for sur-
vivors of critical illness are diverse and span five major
themes: (1) patient physical and psychological influences;
(2) safety influences; (3) culture and team influences; (4)
motivations and beliefs regarding the benefits and risks
of PA; and (5) environmental influences. Our review is
unique in that we have examined this issue across the
care pathway from ICU to community. Many of the bar-
riers and enablers identified were consistent across both
quantitative and qualitative study design and across dif-
ferent geographical settings worldwide, thus improving
the generalizability of findings. Our results are consistent
with previous research investigating barriers specifically
in the ICU setting [10], and extend our understanding of
the challenges in both the ICU and post-ICU settings. We
have identified a number of potentially modifiable barri-
ers and a variety of enablers, which need to be targeted to
inform future research, clinical practice, service delivery
and policy to improve survivorship outcomes (Fig.3).
Upon reflection of the main barriers identified in this
review a central enabling factor across both the ICU
and post-ICU setting which needs to be addressed is
knowledge transfer and education of HCPs, patients
and caregivers. is education includes the need to raise
awareness of the burden and impact of post-intensive
care syndrome, and the importance and benefit of PA
interventions commencing early and continuing post dis-
charge from the ICU setting. Expertise development and
skill training to equip the clinicians to undertake success-
ful PA interventions are also required.
Behavioural change and translation research models
need to be explored to identify potential interventions
and policies which can be targeted to increase PA lev-
els in survivors of critical illness [80]. ere are a vari-
ety of different models that currently exist and could be
adopted in the clinical setting to improve implementa-
tion of PA interventions. For the purposes of this review
we will discuss one model known as the COM-B model
(capability, opportunity, motivation-behaviour) which is
frequently utilised to facilitate evidence translation and
Diagnosis & illness severity, age &
comorbidies
Sedaon, delirium & pain
Pt psychological state (e.g. movaon)
Enablers
Physiological stability
Concern for line safety & risk of line removal
Concern for risk of HCP or caregiver injury
Poor culture, teamwork, &leadership
Lack of experse & skill training
Need for physician orders prior to rehab
•Sedaon, delirium & pain management
•Paent goal seng & family involvement
•Sleep
•Establish instuonal safety guidelines for PA
•Removal / secure of lines
•Educaon re: safety with lines in situ and PA
Barriers
•Develop posive culture, MDT team meengs
•Interprofessional experse / skill training
•Ward rounds & site visits to est programs
•Roune mobility orders
•Designated leaders & discipline champions
Movaons & beliefs regarding the benefit
/ harm of PA intervenons
•Educaon re: importance & benefit of PA
•Posive experiences / storytelling of success
Lack of funding & access to PT services
Lack of equipment, resources & staffing
Lack of me & compeng priories
•Automac referral pathways for PA intervenons
•Illustrate cost saving benefit / business case
•Dedicated equipment & staffing
•Coordinaon of schedules within MDT
•Mobility protocol, ABCDE bundle & mobility team
Fig. 3 Barriers and enablers to delivery of physical activity interventions in individuals with critical illness. ABCDE awakening and breathing coordi-
nation, delirium monitoring and management, early mobility, est established, HCP healthcare provider, MDT, multidisciplinary, PA physical activity, Pt
patient. This figure provides an overview of the identified barriers and enablers across the 89 papers included in this review. The barriers highlighted
in bold are modifiable barriers which can be targeted in specific interventions and policies to improve delivery of PA interventions in individuals
with critical illness

development of interventions to change behaviour, in this
instance healthcare or patient behaviour [80]. e model
can assist in identifying specific intervention strategies
and supporting policies to solidify behaviour change
based on the identified ‘barrier’ sources of behaviour. To
our knowledge this specific behavioural change model
has not been used in the ICU literature previously, and
our data offer a roadmap for effective improvements in
engagement and delivery of PA-based interventions. To
change behaviour, one or multiple aspects of the COM-B
model can be targeted [80]. For example, identified
capability-related barriers included physical (symptoms,
illness severity, delirium, weakness) and psychological
(anxiety, lack of confidence) factors; opportunity-related
barriers included lack of access to services (staffing and
equipment) and competing priorities; and motivation-
related barriers included fear of PA, perceived impor-
tance and unit culture practices (Fig. 4). In contrast
enablers for PA mapped to the COM-B domains included
good sedation and delirium management, safety frame-
works, adoption of ABCDE bundles (capability); devel-
opment of mobility daily care plans, team meetings,
administration buy-in, creation of leadership and ‘mobil-
ity’ champions/protocols (opportunity); and anticipated
benefits from PA (motivation). Based on this framework
and our results, potential interventions may include edu-
cation (of patients, caregivers and HCPs), persuasion (of
HCPs and patients) of the importance and need for PA
interventions, environmental restructuring, modelling
and enablement [80]. Future research and clinical prac-
tice need to focus on educational models, which can be
implemented for HCPs across the MDT and consumers
(patients and caregivers). is includes integration of
education about PA for survivors of critical illness into
both university curricula and clinical training to enable
greater understanding of the importance of engage-
ment and MDT collaboration in PA interventions; and to
equip the MDT with the necessary skills and expertise to
engage patients in PA in the ICU and post-ICU settings.
It is also important that the general public awareness of
the burden of ICU survivorship and importance of PA is
raised, and greater engagement from patients and car-
egivers to understand and develop feasible and realistic
PA-based interventions is required.
We found many transferrable positive examples of
quality improvement projects where individual health
services or groups have gone through an implementa-
tion process to examine local institutional barriers and
enablers. A site-by-site or service-by-service approach to
implement PA across the care continuum is likely needed,
based on individual variation of barriers and enablers,
which may be affected by a disparity between perceived
and actual barriers. It is clear that a team-based approach
with both bottom-up (discipline champions, knowledge
and skills of HCPs, patients and caregivers) and top-
down support (managerial/hospital support) is key to
affecting change.
Barriers and enablers need to be additionally consid-
ered across the trajectory of recovery. Several studies
highlighted that there is a significant gap in access to
rehabilitation post ICU [26, 46, 67]. e majority of stud-
ies included in this review focused on the ICU setting
alone; there is a greater need to understand the chang-
ing barriers for individuals following critical illness once
they leave the hospital setting to reintegrate into the
community setting. From the studies which examined
post ICU it appears that patients may prefer individual-
ised rehabilitation based on illness trajectory rather than
being included in a generic or even respiratory-specific
rehabilitation program such as pulmonary rehabilitation
[67]. Methods to deliver PA programs within existing
infrastructure to utilise resources more efficiently should
be explored. We should also consider low-cost, high-effi-
cacy interventions such as telemonitoring and telephone-
based interventions to increase community PA levels,
which are being investigated in other patient populations
[81].
Critique ofthe method
is review is strengthened by inclusion of qualita-
tive and quantitative data. Qualitative data enriches our
understanding of subjective influences, which are not
captured within quantitative methodologies. We followed
a robust protocol that was registered a priori, adopted
review guidelines, and incorporated duplicate screening
and data extraction to enhance review rigour. However
there are several limitations with this review: our results
were presented using thematic analysis, and thus did not
rate or weight the barriers and enablers in terms of fre-
quency of occurrence because of the differences in study
design and methodologies across included studies. ere
is a risk of publication bias in this review as we only
included studies published in English in a peer-reviewed
journal. All studies were included regardless of risk of
bias and thus results should be interpreted with caution.
Future directions include understanding why the identi-
fied barriers in this review exist and examining whether
the adoption of behavioural change or translational mod-
els to provide targeted interventions to address these bar-
riers is effective in improving patient engagement in PA
interventions in the ICU and post-ICU setting.
Conclusion
Barriers and enablers to PA in patients with critical ill-
ness are multidimensional and span diverse factors.
Considering these factors in a structured behavioural

change framework has elucidated potential strategies
for enhancing interventions, clinical service delivery and
policy frameworks to increase PA in patients with critical
illness.
Electronic supplementary material
The online version of this article (doi:10.1007/s00134-017-4685-4) contains
supplementary material, which is available to authorized users.
Abbreviations
ABCDE: Awakening and breathing coordination, delirium monitoring and
management, early mobility; COM-B: Capability, opportunity, motivation
behavioural change wheel; COREQ: Consolidated criteria for reporting
qualitative studies; ECMO: Extracorporeal membrane oxygenation; ENTREQ:
Enhancing transparency in reporting the synthesis of qualitative research;
HCP: Healthcare provider; ICU: Intensive care unit; ICUAW: Intensive care unit
acquired weakness; MDT: Multidisciplinary team; MV: Mechanical ventilation;
NOS: Newcastle Ottawa scale; PA: Physical activity; PRISMA: Preferred reporting
items for systematic reviews and meta-analyses; QI: Quality improvement.
Authors contribution statement
All authors contributed to the acquisition, analysis and interpretation of data
and were involved in the critical revision of the manuscript for important intel-
lectual content. SP and CG contributed to study concept and design. SP, CG,
PM, ZP, CB and BC drafted the manuscript. SP is funded by a National Health
and Medical Research Council (NHMRC) Early Career Fellowship and was a
recipient of a short-term European Respiratory Society (ERS) travelling fellow-
ship. CG is partially funded by a NHMRC Translating Research into Practice
Fellowship co-funded by Cancer Australia. BC is funded by a National Institute
of Health Research (NIHR) Postdoctoral Fellowship. BC and NH are suppor ted
by the NIHR Biomedical Research Centre based at Guy’s and St. Thomas’ NHS
Foundation Trust and King’s College London. The views expressed are those of
BC and NH and are not necessarily those of the NHS, the NIHR or the Depart-
ment of Health.
Capability
PHYSICAL:
-Patient admission
diagnosis & severity of
illness
-Comorbidities
-Symptoms
-Sedation & delirium
-Physiological stability
PSYCHOLOGICAL:
-Patient trust
-Patient mood, anxiety,
depression
-Patient understanding
of rationale of PA
Opportunity
PHYSICAL:
-Fragmentation of care
-MD referral
-Leadership
-HCPs knowledge & training
-Funding, time, dedicated
space, staff and equipment
-Scheduling conflicts
-Protocols & mobility teams
SOCIAL:
-Carers and relatives
influence
-Encouragement from
HCPs
-Patient preference for
individualised care
Motivation
AUTOMATIC:
-Unit culture
-HCPs / patients / carers
experienced impact of
PA
-HCPs preceived
relevance of PA
REFLECTIVE:
-HCPs concern for line
safety including ETT
-HCPs concern for injury
of self, patient or carer
Behaviour
- Physical Activity -
Fig. 4 Results factors (barriers and enablers) influencing physical activity in individuals with critical illness mapped to the COM-B model. COM-B
‘capability, opportunity and motivation-behaviour’ system, ET T endotracheal tube, HCP healthcare provider, PA physical activity

Author details
1 Department of Physiotherapy, School of Health Sciences, The University
of Melbourne, Level 7 Alan Gilbert Building, Parkville, Melbourne, VIC 3010,
Australia. 2 Department of Physiotherapy, Royal Melbourne Hospital, Mel-
bourne, VIC, Australia. 3 Guy’s and St Thomas’ NHS Foundation Trust and King’s
College London National Institute of Health Research Biomedical Research
Centre, London, UK. 4 Centre of Human and Aerospace Physiological Sciences,
King’s College London, London, UK. 5 Lane Fox Clinical Respiratory Physiology
Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK.
6 International Centre for Allied Health Evidence (iCAHE) and the Sansom Insti-
tute, University of South Australia, Adelaide, SA, Australia. 7 Division of Critical
Care, Institute of Sports and Exercise Health, University College Hospitals,
London, UK. 8 Division of Asthma, Allergy and Lung Biology, King’s College
London, London, UK. 9 Department of Critical Care, University of Kentucky,
Lexington, USA. 10 Institute for Breathing and Sleep, Melbourne, VIC, Australia.
Compliance with ethical standards
Conflicts of interest
The authors have no other formal conflicts of interest to declare.
Received: 3 November 2016 Accepted: 10 January 2017
References
1. Herridge MS, Moss M, Hough CL, Hopkins RO, Rice TW, Bienvenu OJ,
Azoulay E (2016) Recovery and outcomes after the acute respiratory
distress syndrome (ARDS) in patients and their family caregivers. Intensive
Care Med 42(5):725–738
2. Kayambu G, Boots R, Paratz J (2013) Physical therapy for the critically
ill in the ICU: a systematic review and meta-analysis. Crit Care Med
41(6):1543–1554
3. Hashem M, Nelliot A, Needham D (2016) Early mobilization and rehabili-
tation in the ICU: moving back to the future. Respir Care 61(7):971–979
4. Caspersen CJ, Powell KE, Christenson GM (1985) Physical activity, exercise,
and physical fitness: definitions and distinctions for health-related
research. Public Health Rep 100(2):126–131
5. National Institute for Health and Clinical Excellence (2009) Rehabilitation
after critical illness. NICE clinical guideline, vol 83. National Institute for
Health and Clinical Excellence, Manchester
6. Berry A, Beattie K, Bennett J, Cross , Cushway S, Hassan A, Longhurst E,
Moore R, Phillips D, Plowman E, Scott J, Thomas L, Elliott D (2014) Physi-
cal activity and movement: a guideline for critically ill adults, in SHPN.
Agency for Clinical Innovation, Chatswood
7. Berney SC, Rose JW, Bernhardt J, Denehy L (2015) Prospective observa-
tion of physical activity in critically ill patients who were intubated for
more than 48 hours. J Crit Care 30(4):658–663
8. Berney S, Harrold M, Webb S, Seppelt I, Patman S, Thomas P, Denehy L
(2013) Intensive care unit mobility practices in Australia and New Zea-
land: a point prevalence study. Crit Care Resusc 15(4):260–265
9. Nydahl P, Ruhl A, Bartoszek G, Dubb R, Filipovic S, Flohr H-J, Kaltwasser
A, Mende H, Rothaug O, Schuchhardt D, Schwabbauer N, Needham D
(2014) Early mobilization of mechanically ventilated patients: a 1-day
point-prevalence study in Germany. Crit Care Med 42(5):1178–1186
10. Dubb R, Nydahl P, Hermes C, Schwabbauer N, Toonstra A, Parker Kaltwas-
ser A, Needham D (2016) Barriers and strategies for early mobilization in
intensive care units. Ann Am Thorac Soc 36:2238–2243
11. Honiden S, Connors G (2015) Barriers and challenges to the successful
implementation of an intensive care unit mobility program: understand-
ing systems and human factors in search for practical solutions. Clin
Chest Med 36(3):431–440
12. Parry SM et al (2016) What are the factors that impact on physical activity
and rehabilitation for survivors of critical illness: Asystematic review of
quantitative and qualitative studies. Intensive Care Med Exp 4 (Suppl 1):
A40
13. Moher D, Liberati A, Tetzlaff J, Altman D, PRISMA Group (2009) Preferred
reporting items for systematic reviews and meta-analyses: the PRISMA
statement. PLoS Med 6:e1000097. doi:10.1371/journal.pmed.1000097
14. Tong A, Flemming K, McInnes E, Oliver S, Craig J (2012) Enhancing trans-
parency in reporting the synthesis of qualitative research: ENTREQ. BMC
Med Res Methodol 12(181):1–8
15. Tong A, Sainsbury P, Craig J (2007) Consolidated criteria for reporting
qualitative research (COREQ): a 32-item checklist for interviews and focus
groups. Int J Qual Health Care 19(6):349–357
16. Thomas J, Harden A (2008) Methods for the thematic synthesis of qualita-
tive research in systematic reviews. BMC Med Res Methodol 8:45
17. Harrold M, Salisbury L, Webb S, Allison G (2015) Early mobilisation in inten-
sive care units in Australia and Scotland: a prospective, observational cohort
study examining mobilisation practises and barriers. Crit Care 19(1):336
18. Pohlman M, Schweickert W, Pohlman A, Nigos C, Pawlik A, Esbrook C,
Spears L, Miller M, Franczyk M, Deprizio D, Schmidt G, Bowman A, Barr R,
McCallister K, Hall J, Kress J (2010) Feasibility of physical and occupational
therapy beginning from initiation of mechanical ventilation. Crit Care
Med 38(11):2089–2094
19. Castro E, Turcinovic M, Platz J, Law I (2015) Early mobilization: changing
the mindset. Criti Care Nurs 35(4):e1–e5
20. TEAM Study Investigators, Hodgson C, Bellomo R, Berney S, Bailey M, Buhr
H, Denehy L, Harrold M, Higgins A, Presneill J, Saxena M, Skinner E, Young
P, Webb S (2015) Early mobilization and recovery in mechanically venti-
lated patients in the ICU: a bi-national, multi-centre, prospective cohort
study. Crit Care 19:81
21. Needham D, Korupolu R (2010) Rehabilitation quality improvement in
an intensive care unit setting: implementation of a quality improvement
model. Topic Stroke Rehabil 17(4):271–281
22. Morris P, Goad A, Thompson C, Taylor K, Harry B, Passmore L, Ross A,
Anderson L, Baker S, Sanchez M, Penley L, Howard A, Dixon L, Leach
S, Small R, Hite R, Haponik E (2008) Early intensive care unit mobility
therapy in the treatment of acute respiratory failure. Crit Care Med
36(8):2238–2243
23. Berney S, Haines K, Skinner E, Denehy L (2012) Safety and feasibility of an
exercise prescription approach to rehabilitation across the continuum of
care for survivors of critical illness. Phys Ther 92(12):1524–1535
24. Knott A, Stevenson M, Harlow S (2015) Benchmarking rehabilitation
practice in the intensive care unit. J Intensive Care Soc 16(1):24–30
25. Dammeyer J, Baldwin N, Packard D, Harrington S, Christofferson B, Chris-
topher J, Strachan C, Iwashyna J (2013) Mobilizing outcomes: implemen-
tation of a nurse-led multidisciplinary mobility program. Crit Care Nurs
Quart 36(1):109–119
26. Appleton R, MacKinnon M, Booth M, Wells J, Quasim T (2011) Rehabilita-
tion within Scottish intensive care units: a national survey. J Intensive
Care Soc 12(3):221–227
27. Winkelman C, Peereboom K (2010) Staff-perceived barriers and facilita-
tors. Crit Care Nurse 30(2):S13–S16
28. Mendez-Tellez P, Dinglas V, Colantuoni E, Ciesla N, Sevransky J, Shanholtz
C, Pronovost P, Needham D (2013) Factors associated with timing of
initiation of physical therapy in patients with acute lung injury. J Crit Care
28(6):980–984
29. McWilliams D, Pantelides K (2008) Does physiotherapy led early mobilisation
affect length of stay in ICU? Assoc Chart Physiother Respir Care J 40:5–10
30. Dinglas V, Colantuoni E, Ciesla N, Mendez-Tellez P, Shanholtz C, Needham
D (2013) Occupational therapy for patients with acute lung injury: factors
associated with time to first intervention in the intensive care unit. Am J
Occup Ther 67(3):355–362
31. Harris C, Shahid S (2014) Physical therapy-driven quality improvement
to promote early mobility in the intensive care unit. Bayl Univ Med Cent
Proc 27(3):203–207
32. Zanni J, Korupolu R, Fan E, Pradhan P, Janjua K, Palmer J, Brower R, Need-
ham D (2010) Rehabilitation therapy and outcomes in acute respiratory
failure: an observational pilot project. J Crit Care 25(2):254–262
33. Engel H, Tatebe S, Alonzo P, Mustille R, Rivera M (2013) Physical therapist-
established intensive care unit early mobilization program: quality
improvement project for critical care at the University of California San
Francisco Medical Center. Phys Ther 93:975–985
34. Bassett R, McCutcheon Adams K, Danesh V, Groat P, Haugen A, Kiewel
A, Small C, Van-Leuven M, Venus S, Ely E (2015) Rethinking critical care:
decreasing sedation, increasing delirium monitoring, and increasing
patient mobility. Jt Comm J Qual Patient Saf 41(2):62–74

35. Jolley S, Caldwell E, Hough C (2014) Factors associated with receipt of
physical therapy consultation in patients requiring prolonged mechani-
cal ventilation. Dimens Criti Care Nurs 33(3):160–167
36. Jolley S, Dale C, Hough C (2015) Hospital-level factors associated with
report of physical activity in patients on mechanical ventilation across
Washington State. Ann Am Thorac Soc 12(2):209–215
37. Jolley S, Regan-Baggs J, Dickson R, Hough C (2014) Medical intensive care
unit clinician attitudes and perceived barriers towards early mobilization of
critically ill patients: a cross-sectional survey study. BMC Anaesthesiol 14:84
38. Tadyanemhandu C, Manie S (2015) Profile of patients and physiotherapy
patterns in intensive care units in public hospitals in Zimbabwe: a
descriptive cross-sectional study. BMC Anaesthesiol 15:136
39. Davis J, Crawford K, Wierman H, Osgood W, Cavanaugh J, Smith K, Mette
S, Orff S (2013) Mobilization of ventilated older adults. J Geriatr Phys Ther
36(4):162–168
40. Malone D, Ridgeway K, Nordon-Craft A, Moss P, Schenkman M, Moss M
(2015) Physical therapist practice in the intensive care unit: results of a
national survey. Phys Ther 95(10):1335–1344
41. Barber E, Everard T, Holland A, Tipping C, Bradley S, Hodgson C (2015)
Barriers and facilitators to early mobilisation in intensive care: a qualitative
study. Aust Crit Care 28(4):177–182
42. Leditschke A, Green M, Irvine J, Bissett B, Mitchell I (2012) What are the barri-
ers to mobilizing intensive care patients? Cardiopulm Phys Ther 23(1):26–29
43. Williams N, Flynn M (2013) An exploratory study of physiotherapist’s
views of early rehabilitation in critically ill patients. Physiother Practi Res
34(2):93–102
44. Bakhru R, Wiebe D, McWilliams D, Spuhler V, Schweickert W (2015) An
environmental scan for early mobilization practices in US ICUs. Crit Care
Med 43(11):2360–2369
45. Eakin M, Ugbah L, Arnautovic T, Parker A, Needham D (2015) Implement-
ing and sustaining an early rehabilitation program in a medical intensive
care unit: a qualitative analysis. J Crit Care 30(4):698–704
46. Hopkins R, Spuhler V, Thomsen G (2007) Transforming ICU culture to
facilitate early mobility. Crit Care Clin 23(1):81–96
47. Miller M, Govindan S, Watson S, Hyzy R, Iwashyna T (2015) ABCDE, but
in that order? A cross-sectional survey of Michigan intensive care unit
sedation, delirium, and early mobility practices. Ann Am Thorac Soc
12(7):1066–1071
48. Hopkins R, Spuhler V (2009) Strategies for promoting early activity
in critically ill mechanically ventilated patients. AACN Adv Crit Care
20(3):277–289
49. Bailey P, Thomsen G, Spuhler V, Blair R, Jewkes J, Bezdijian L, Veale K, Rod-
riguez L, Hopkins R (2007) Early activity is feasible and safe in respiratory
failure patients. Crit Care Med 35(1):139–145
50. Brummel N, Girard T, Ely E, Pandharipande P, Morandi A, Hughes C, Graves
A, Shintani A, Murphy E, Work B, Pun B, Boehm Gill L, Dittus R, Jackson J
(2014) Feasibility and safety of early combined cognitive and physical
therapy for critically ill medical and surgical patients: the activity and
cognitive therapy in ICU (ACT-ICU) trial. Intensive Care Med 40(3):370–379
51. Garzon-Serrano J, Ryan C, Waak K, Hirschberg R, Tully S, Bittner E, Chipman
D, Schmidt U, Kasotakis G, Benjamin J, Zafonte R, Eikermann M (2011) Early
mobilization in critically ill patients: patient’s mobilization level depends
on health care provider’s profession. Phys Med Rehabil 3(4):307–313
52. Holdsworth C, Haines K, Francis J, Marshall A, O’Connor D, Skinner E
(2015) Mobilization of ventilated patients in the intensive care unit:
an elicitation study using the theory of planned behavior. J Crit Care
30(6):1243–1250
53. King J, Crowe J (1998) Mobilization practices in Canadian critical care
units. Physiotherapy 50(3):206–211
54. Perme C, Lettvin C, Throckmorton T, Mitchell K, Masud F (2011) Early
mobility and walking for patients with femoral arterial catheters in inten-
sive care unit: a case series. J Acute Care Phys Ther 2(1):30–34
55. Perme C, Nalty T, Winkelman C, Nawa R, Masud F (2013) Safety and
efficacy of mobility interventions in patients with femoral catheters in the
ICU: a prospective observational study. Cardiopulm Phys Ther 24(2):12–17
56. Dalmuji A, Zanni J, Mantheiy E, Colantuoni E, Kho M, Needham D (2013)
Safety and feasibility of femoral catheters during physical rehabilitation in
the intensive care unit. J Crit Care 28(4):535.e9–535.e15
57. Wang Y, Haines T, Ritchie P, Walker C, Ansell T, Ryan D, Lim P, Vij S, Acs R,
Fealy N, Skinner E (2014) Early mobilization on continuous renal replace-
ment therapy is safe and may improve filter life. Crit Care 18(4):R161
58. Toonstra A, Zanni J, Sperati J, Nelliot A, Mantheiy E, Skinner E, Needham
D (2016) Feasibility and safety of physical therapy during continuous
renal replacement therapy in the intensive care unit. Ann Am Thorac Soc
13(5):699–704
59. Bassett R, Vollman K, Brandwene L, Murray T (2012) Integrating a multi-
disciplinary mobility programme into intensive care practice (IMMPTP): a
multicentre collaborative. Intensive Crit Care Nurs 28(2):88–97
60. Carrothers K, Barr J, Spurlock B, Ridgely M, Damberg C, Ely E (2013)
Contextual issues influencing implementation and outcomes associated
with an integrated approach to managing pain, agitation, and delirium in
adult ICUs. Crit Care Med 41(9 Suppl 1):S128–S135
61. Reames C, Price D, King E, Dickinson S (2016) Mobilizing patients along
the continuum of critical care. Dimens Crit Care Nurs 35(1):10–15
62. Balas M, Burke W, Gannon D, Cohen M, Colburn L, Bevil C, Franz D, Olsen
K, Ely E, Vasilevskis E (2013) Implementing the awakening and breathing
coordination, delirium monitoring/management, and early exercise/
mobility bundle into everyday care: opportunities, challenges, and
lessons learned for implementing the ICU pain, agitation, and delirium
guidelines. Crit Care Med 41(9 Suppl 1):S116–S127
63. Messer A, Corner L, Forst S (2015) Implementation of a progressive mobilization
program in a medical-surgical intensive care unit. Crit Care Nurse 35(5):28–42
64. Walker W, Wright J, Danjoux G, Howell S, Martin D, Bonner S (2015) Project
post intensive care exercise (PIX): a qualitative exploration of intensive
care unit survivors’ perceptions of quality of life post-discharge and
experience of exercise rehabilitation. J Intensive Care Soc 16(1):37–44
65. Deacon K (2012) Re-building life after ICU: a qualitative study of the
patient’s perspective. Intensive Crit Care Nurs 28(2):114–122
66. Czerwonka A, Herridge M, Chan L, Chu L, Matte A, Cameron J (2015)
Changing support needs of survivors of complex critical illness and their
family caregivers across the care continuum: a qualitative pilot study of
towards RECOVER. J Crit Care 30(2):242–249
67. Connolly B, Thompson A, Douiri A, Moxham J, Hart N (2015) Exercise-
based rehabilitation after hospital discharge for survivors of critical illness
with intensive care unit–acquired weakness: a pilot feasibility trial. J Crit
Care 30(3):589–598
68. Sottile P, Nordon-Craft A, Malone D, Schenkman M, Moss M (2015) Patient
and family perceptions of physical therapy in the medical intensive care
unit. J Crit Care 30(5):891–895
69. Needham D, Korupolu R, Zanni J, Pradhan P, Colantuoni E, Palmer J,
Brower R, Fan E (2010) Early physical medicine and rehabilitation for
patients with acute respiratory failure: a quality improvement project.
Arch Phys Med Rehabil 91(4):536–542
70. Connolly B, Douiri A, Steier J, Moxham J, Denehy L, Hart N (2014) A UK sur-
vey of rehabilitation following critical illness: implementation of NICE clinical
guidance 83 (CG83) following hospital discharge. BMJ Open 4:e004963
71. Hodgin K, Nordon-Craft A, McFann K, Mealer M, Moss M (2009) Physical
therapy utilization in intensive care units: results from a national survey.
Crit Care Med 37(2):561–568
72. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook
CL, Spears L, Miller M, Franczyk M, Deprizio D, Schmidt GA, Bowman
A, Barr R, McCallister KE, Hall JB, Kress JP (2009) Early physical and
occupational therapy in mechanically ventilated, critically ill patients: a
randomised controlled trial. Lancet 373(9678):1874–1882
73. Dafoe S, Stiller K, Chapman M (2015) Staff perceptions of the barriers to
mobilizing ICU patients. Internet J Allied Health Sci Pract 13(2):1–13
74. Dafoe S, Chapman M, Edwards S, Stiller K (2016) Overcoming barriers to
the mobilisation of patients in an intensive care unit. Anaesth Intensive
Care 44(2):185–324
75. Dinglas V, Parker A, Reddy D, Colantuoni E, Zanni J, Turnbull A, Nelliot A,
Ciesla N, Needham D (2014) A quality improvement project sustain-
ably decreased time to onset of active physical therapy intervention in
patients with acute lung injury. Ann Am Thorac Soc 11(8):1230–1238
76. Fraser D, Spiva L, Forman W, Hallen C (2015) Original research: implemen-
tation of an early mobility program in an ICU. Am J Nurs 115(12):49–58

77. Wahab R, Yip N, Chandra S, Nguyen M, Pavlovich K, Benson T, Vilotijevic D,
Rodier D, Patel K, Rychcik P, Perez-Mir E, Boyle S, Berlin D, Needham D, Brodie
D (2016) The implementation of an early rehabilitation program is associated
with reduced length of stay: a multi-ICU study. J Intensive Care Soc 17(1):2–11
78. Hanekom S, Louw Q, Coetzee A (2013) Implementation of a protocol
facilitates evidence-based physiotherapy practice in intensive care units.
Physiotherapy 99(2):139–145
79. Lee C, Herridge M, Matte A, Cameron J (2009) Education and support
needs during recovery in acute respiratory distress syndrome survivors.
Crit Care 13:R153
80. Michie S, van Stralen M, West R (2011) The behaviour change wheel: a
new method for characterising and designing behaviour change inter-
ventions. Implement Sci 23(6):42
81. Tabak M, Vollenbroek-Hutten M, van der Valk P, van der Pale J, Hermens H
(2014) A telerehabilitation intervention for patients with chronic obstruc-
tive pulmonary disease: a randomized controlled pilot trial. Clin Rehabil
28(6):582–591