Physical Activity of the Patient in ICU

【Major Points】

Physical activity promotes blood circulation and maintains joint mobility.
The frequency and range of physical activity must be increased gradually.
Physical activity should not be performed when there is an injection or dialysis line in the joint.
For each joint, 10-20 repetitions of a physical activity may be performed at a time.

What is physical activity?

Physical activity is categorized into active movement (movement by oneself) and passive movement (movement assisted by another person or a device, such as bicycle on bed).

Why is physical activity needed?

Physical activity can promote blood circulation, prevent limb contracture and deformation, and maintain joint mobility and muscle strength.

Patients in the ICU are often confined to bed due to medical conditions or treatment needs (e.g., stroke causing limb weakness, general paralysis from severe trauma, and prolonged use of sedatives and sleeping medications).
Prolonged immobilization of the body or limbs prevents the joints from reaching their maximum angle of extension, resulting in joint contractures, deformities, and muscle weakness.

What should be prepared before physical activity?

Explain the purpose and importance of the activity to a conscious patient to encourage cooperation.
Encourage patients who can move somewhat independently to perform the activity on their own, but ensure that they are accompanied by someone to monitor their safety.
If the patient experiences muscle spasms or resistance before starting the physical activity, do not force the patient to perform the activity. Wait until the muscle relaxes, and then have the patient gradually begin the activity.

How is physical activity performed?
Physical activity can be divided into exercises for upper limb joints (such as fingers, wrists, elbows, and shoulders) and lower limb joints (such as toes, ankles, knees, and hips), covering a total of eight joints. This exercise is typically performed once or twice a day, with 10-20 repetitions for each joint per session.

Physical activity for upper limb joints
1. Fingers
  - Flexion and extension: Bend the fingers into a fist, and then open and extend the fingers. (see Figure 1)
    
    Figure 1. Finger flexion and extension
  - Abduction and adduction: Abduct the patient’s fingers and return them to their original position. (see Figure 2)
    
    Figure 2. Finger abduction and adduction
2. Wrist
  - Flexion and extension: Support the patient’s forearm with one hand. Then, bend and straighten the patient’s wrist toward the forearm with the other hand. (see Figure 3)
    
    Figure 3. Wrist flexion and extension
  - Rotation: Rotate the hand upward, downward, leftward, and rightward.
3. Elbow
  - Flexion and extension: Hold the patient’s upper arm with one hand while supporting their wrist with the other. Bend and straighten the arm toward the upper arm. (see Figure 4)
    
    Figure 4. Elbow flexion and extension
  - Inward and outward rotation: Rotate the forearm inward and outward. (see Figure 5)
    
    Figure 5. Inward and outward elbow rotation
4. Shoulder
  - Horizontal abduction and adduction: Extend the patient’s arm horizontally to 90 degrees away from the side of the body, then move it across the anterior chest and adduct it to 90 degrees. (see Figure 6)
    
    Figure 6. Horizontal shoulder abduction and adduction
  - Forward extension and flexion: Lift the patient’s arm forward and up to ear level, then lower it back to its original position. (see Figure 7)
    
    Figure 7. Forward shoulder extension and flexion
  - Rotation: Support the patient’s shoulder with one hand and place the other hand on the forearm to facilitate shoulder rotation.
Physical activity for lower limb joints
1. Toes
  - Flex the patient’s five toes and extend them to stretch.
2. Ankle joint
  - Flexion and extension: Hold the patient’s instep with one hand and their calf with the other. Then, bend it upward and straighten it. (see Figure 8)
    
    Figure 8. Ankle joint flexion and extension
  - Inward and outward rotation: Hold the patient’s ankle with one hand and rotate the foot to turn the sole inward and outward.
3. Knee joint
  - Flexion and extension: Hold the patient’s calf with one hand and their thigh near the knee with the other hand. Bend the foot and then straighten it. (see Figure 9)
    
    Figure 9. Knee and hip joint flexion and extension
4. Hip joint
  - Flexion and extension: Hold the patient’s calf with one hand and their thigh near the knee with the other hand. Bend the foot and then straighten it. (see Figure 9)
  - Abduction and adduction: Stand at the side while supporting the patient’s calf with one hand and putting the other hand below the knee. Open the leg outward to 45 degrees before returning it to its original position. (see Figure 10)
    
    Figure 10. Hip joint abduction and adduction

What should I pay attention to when performing a physical activity?

All movements should be performed slowly and gently, with careful observation of the patient’s response. The number and range of movements may be increased gradually. If the pain is unbearable, the activity should be suspended.
The operator should support the patient’s joints at both ends, starting from the finger (or toe) joints to the proximal joints of the torso.
The activity must be performed on a joint-by-joint basis, moving to the next joint only after completing the activity for the current one.
The activity should not be performed if there is an injection, surgical wound, or dialysis line present in the joint where the activity is intended to be performed.
The operator should stand on the same side as the patient when performing the activity, positioning themselves as close to their body as possible to avoid physical exertion.

Reference

Bickenbach, J., Fritsch, S., Cosler, S., Simon, Y., Dreher, M., Theisen, S., Kao, J., Hildebrand, F., Marx, G., & Simon, T. P. (2024). Effects of structured protocolized physical therapy on the duration of mechanical ventilation in patients with prolonged weaning. Journal of Critical Care, 80, 154491. https://www.sciencedirect.com/science/article/pii/S088394412300240X
Huang, Y. C. , Chao, I. C., Chen, S. H., Chang, Y. M., Chen, Y. J., & Wu, H. H.(2023).Effectiveness of rehabilitation exercise training in patients with prolonged mechanical ventilation using the intensive care unit mobility scale. Medical Journal of South Taiwan,19(2), 42-49. https://www.airitilibrary.com/Article/Detail/19914784-N202312280013-00001
Potter, K., Miller, S., & Newman, S. (2021). Environmental factors affecting early mobilization and physical disability post–intensive care: An integrative review through the lens of the World Health Organization International Classification of Functioning, Disability, and Health. Dimensions of Critical Care Nursing, 40(2), 92-117. https://pubmed.ncbi.nlm.nih.gov/33961378/
Yang, X., Zhang, T., Cao, L., Ye, L., & Song, W. (2023). Early mobilization for critically lll patients. Respiratory Care, 68(6), 781-795. https://doi.org/10.4187/respcare.10481
Zakeri, M. A., Aziz, A. R., Rahiminezhad, E., & Dehghan, M. (2023). Effectiveness of massage and range of motion exercises on muscle strength and intensive care unit-acquired weakness in Iranian patients with COVID-19: A randomized parallel-controlled. Acute and Critical Care. https://accjournal.org/journal/view.php?number=1484

Physical Activity of the Patient in ICU

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