Physical Therapy for Post-Intensive Care Syndrome

Post-intensive care syndrome (PICS) is a collection of symptoms, limitations, and impairments that are present in people who have recently been treated in a hospital’s intensive care unit (ICU). These impairments may be chronic and may limit your full participation in your normal activities upon discharge from the ICU.

If you have been recently discharged from the intensive care unit, you may benefit from the care of a physical therapist to help you recover fully and return to your previous level of work and recreational activity.

The global health pandemic caused by the COVID-19 virus has created a situation where more people may require the need for ICU care. As these people recover from the virus and are discharged from the hospital, they may require significant healthcare services and resources to fully recover.

A significant number of people may present with PICS and need to engage in long-term rehabilitation. Physical therapy may be one important piece in the rehab and recovery process for people with PICS.

Symptoms of Post-Intensive Care Syndrome

Not every patient who receives care in the ICU develop PICS. Factors that may increase your risk of developing PICS may include:

• Mechanical ventilation of greater than 48 hours
• Female gender
• Older age
• Delirium during ICU stay

Understanding the symptoms of PICS can help you identify if you may have it. Post-intensive care syndrome is a collection of symptoms; you may have a few or many. The symptoms present as physical impairments, cognitive impairments, and mental/emotional impairments.

Physical Impairments

If you have PICS, you may experience significant physical impairments that create difficulty with functional mobility. These impairments may include:

• Loss of strength.
• Loss of range of motion
• Decreased breathing ability
• Decreased endurance
• Slower walking speed
• Decreased balance
• Decreased activities of daily living (ADLs)

A significant number of people with PICS have difficulty returning to their full functional status after their ICU treatment. Many do not return to their previous level of employment, and some people require significant rehab to return to independent driving and engagement in their community.

Cognitive Impairments

Cognitive impairment may also be present after a stay in the intensive care unit. Problems with attention, memory, and concentration may be present. One study found that approximately half of survivors of acute respiratory distress syndrome (ARDS) experience some form of cognitive impairment, and this may persist for two years or more after leaving the hospital.

These cognitive impairments may be worsened by the presence of physical limitations and mental impairments. Screening for cognitive impairments is essential upon discharge from the ICU.

Mental Health

Some survivors of critical illness and an ICU stay experience significant mental impairments. This may include depression, anxiety, and symptoms of post-traumatic stress disorder.

While mental health care may fall outside of the scope of practice for your physical therapist, he or she may question you about your feelings to screen for any mental health impairment. If you do exhibit signs of a problem, referral to an appropriate provider can be made.

One major problem of PICS is hospital readmission; one study found that about 80% of people discharged from the ICU required hospital or rehab readmission in the subsequent two years. One-third of those hospital readmissions occurred within the first month of discharge from the ICU.

One of the goals of physical therapy for PICS is to help you fully recover. Part of this recovery is to help you avoid being readmitted to the hospital.

If you have been hospitalized in the intensive care unit for any length of time, and if you suspect you may be suffering from PICS, you must see your physician right away. They can coordinate care for you to help you regain mobility, decrease anxiety and depression, and improve your quality of life.

Weakness Due to PICS

About one-third of all patients admitted to the ICU require mechanical ventilation. Since the COVID-19 virus attacks the respiratory system (among other body systems), many hospitalized patients diagnosed with coronavirus require the use of a ventilator. Those that survive and are finally discharged from the ICU may suffer from significant problems.

One major problem of PICS is intensive care unit acquired weakness (ICUAW). This occurs in about 30% of patients who have been ventilated, 80% of patients with sepsis, and in 50% of patients who spend at least one week in the ICU. This weakness can last for up to one year or beyond.

A diagnosis of ICUAW is made by performing manual muscle testing. Your physical therapist (PT) can do it right at your bedside in the hospital or while you are sitting in a chair at home. A score of zero (no muscle contraction) to five (full strength) is assigned to strength tests for various muscle groups. These movements include:

• Shoulder abduction (lifting your arm to the side)
• Elbow flexion (bending your elbow)
• Wrist extension (lifting the back of your hand up)
• Hip flexion (bending your hip up)
• Knee extension (straightening your knee)
• Ankle dorsiflexion (bending your ankle and toes up)

When scored bilaterally, a maximal score of 60 is possible. A score of 48 or less indicates the presence of ICUAW.

Physical therapists are movement and strengthening experts. The role of physical therapy in the management of PICS is important to help you regain strength and endurance so you can function properly.

Multidisciplinary Approach to Care

Since PICS may affect so many different parts of your body and may have a significant impact on your overall function, several healthcare providers may be involved in your care for PICS. These providers may include:

• Physical therapist
• Physician
• Occupational therapist (OT)
• Speech language pathologist (SLP)
• Social worker
• Psychologist

Your friends and family should understand that they may play a critical role in your recovery for PICS. You may require transportation, meal preparation, or help with basic activities of daily living.

Having a strong family and social network can help you with these daily tasks while recovering from PICS. They can serve as a cheerleading squad, can provide encouragement and motivation, and can watch for signs of depression and anxiety. They are an integral part of your care team.

Treatment Locations

After you have been hospitalized in the ICU, you will likely be discharged to a rehab hospital or to your home. If you are admitted to a rehab facility, you will receive services there. Your physical therapist, occupational therapist, and other healthcare professionals will come to your hospital room and assess your condition and help you regain mobility and function.

If you are discharged home, you may benefit from home care services. Your therapy team can come to your home and assess your condition and provide services there.

Once you regain some strength and mobility, you may benefit from going to an outpatient therapy clinic to receive your rehab services. Your physical therapist will have specialized exercise equipment to help you regain full strength, endurance, and mobility.

Physical Therapy for PICS

Your first session with a physical therapist for PICS is called an initial evaluation. During this appointment, your PT will interview you and discuss your course of care thus far.

Be prepared to answer specific questions about your length of hospitalization, your functional status prior to hospitalization, and if and how long you were ventilated. Your PT will ask you about any other rehab services you have received thus far, and they will review your past medical history.

After the interview, your physical therapist will perform an initial evaluation. He or she will measure various things, looking for specific impairments that may be limiting your functional mobility. Common impairments measured include:

• Range of motion
• Gait
• Strength
• Balance
• Respiration
• Endurance

Several outcomes measurement tools may be used to get a sense of your mobility. Your PT may choose to perform the Six Minute Walk Test to assess your endurance and gait speed, or the Timed Up and Go Test may be performed. These simple tests can provide information about your general mobility and can give your therapist a baseline of your function.

If you are walking with an assistive like a cane or a walker, your PT can check that it is sized properly. He or she can also make sure you are using it safely.

Once the evaluation is over, your therapist should have a good idea of your functional mobility and the impairments that may be leading to limitations in your movement. Your therapist will then work with you and your family to develop a plan of care and goals for rehab. Common goals may be to return to full strength, improve balance, and return to normal walking with no assistive device.

Exercise should be your main tool during physical therapy. Your PT will work with you to help improve your strength, balance, mobility, and function. Three areas of focus during rehab are:

• Bed mobility: How well you move around while lying down.
• Transfers: Moving from one position to another, as in rising from bed and sitting in a chair.
• Ambulation: How well you are able to safely walk.

Your therapist can tailor a rehab and exercise program to focus on the areas that are most impaired.

Exercises that may be prescribed after PICS may include:

• Bridges
• Straight leg raises
• Breathing exercises to improve lung function
• Mini squats
• Seated leg extension
• Heel and toe raises
• Single leg standing for balance
• Gait and walking exercises over various surfaces
• Stair climbing
• Aerobic exercises like biking or treadmill walking

Be sure to check in with your physician or PT before doing any exercise if you have PICS.

If you are receiving services for PICS in a rehab hospital, your PT may have joint treatments with an occupational therapist. Your PT and OT may work together to improve standing and walking while performing activities of daily living, like brushing your hair or teeth.

If you are receiving PT at home for PICS, your therapist may be limited in the exercises that can be done. Don't worry—home care PTs are creative and can find ways to work with you to provide challenging activities exercises to improve your mobility.

Outpatient physical therapy for PICS may include using exercise machines to improve strength and endurance. Specific balance tools, like a BOSU ball or BAPS board, may be used to improve balance and proprioception. Stationary bikes, upper body bikes, or treadmills may be available to improve respiratory and aerobic endurance.

Regardless of where you receive your physical therapy services, your PT should communicate your progress with your physician and care team to ensure continuity of care during your rehab. Your PT may need to work closely with your OT, SLP, or psychologist to ensure your emotional, cognitive, and physical needs are met.

Prognosis

The prognosis for people with PICS is variable; some people recover quickly, while others get back to normal more slowly. Your overall recovery may take months or years. The presence of muscle weakness at hospital discharge is associated with reduced health-related quality of life for up to 24 months for people with PICS.

You can expect to receive rehab services for several months after discharge from the intensive care unit, especially if you have significant weakness. You should work closely with your physical therapist, physician, and care team to understand your course of rehab and your overall prognosis.

Most importantly, try to maintain a long-term focus during your rehab. Although your recovery may feel slow, each day you can make small steps to your greater rehab goals.

A Word From Verywell

The COVID-19 pandemic has brought to light the need for long-term care of people who have been ventilated or have spent several days or weeks in the ICU. If you have been in intensive care, you may develop a collection of symptoms that indicate you have PICS. Physical therapy for PICS can help you improve strength, endurance, and safe functional mobility. That way you can return to your previous level of function and activity.