Physiotherapy Assessment of Patients in the ICU

Before any physiotherapy intervention can begin in the intensive care unit, a thorough assessment must be performed. This assessment is the foundation of every treatment plan — without it, even well-intentioned therapy can cause harm. ICU physiotherapy assessment is a structured, systematic process that evaluates the patient's respiratory function, physical capacity, cognitive state, and overall medical stability.

This article explains what a physiotherapy assessment in the ICU involves, what tools and tests are used, and how the findings guide the rehabilitation plan.

Why Assessment in the ICU Is Different

Assessing patients in intensive care presents unique challenges that are not encountered in outpatient or ward-based physiotherapy. ICU patients may be:

• Sedated or minimally conscious
• Mechanically ventilated and unable to speak
• Haemodynamically unstable with fluctuating blood pressure, heart rate, or oxygen levels
• Connected to multiple lines, drains, and monitoring devices that limit movement
• Experiencing delirium, confusion, or significant cognitive impairment
• In significant pain or discomfort

The physiotherapist must interpret information from multiple sources — the patient's medical chart, nursing observations, ventilator settings, and direct physical examination — and integrate these to form a complete clinical picture before making any decisions about treatment.

Safety Screening — The First Step

Before every physiotherapy session, the therapist checks a set of safety criteria to determine whether it is appropriate to proceed with assessment and treatment. These include reviewing:

• Cardiovascular stability: Is the patient's heart rate, blood pressure, and cardiac rhythm within safe limits? Are they on high doses of vasopressors (drugs to maintain blood pressure)?
• Respiratory stability: What are the ventilator settings? What fraction of inspired oxygen (FiO₂) is required? What is the patient's oxygen saturation? Is there evidence of respiratory distress?
• Neurological status: What is the patient's level of consciousness? Are there concerns about raised intracranial pressure?
• Lines and devices: Are there any lines or drains that could be dislodged during movement, and how can this risk be managed?
• Recent procedures or changes: Has the patient had surgery, a procedure, or a significant change in their condition in the past few hours?

Respiratory Assessment

The respiratory assessment examines how effectively the patient is breathing and whether there are any complications that physiotherapy can address. Key components include:

Observation

The physiotherapist observes the patient's breathing pattern — the rate, depth, and regularity of breaths, and whether any accessory muscles (neck, shoulders) are being used. The chest is observed for equal, symmetrical movement on both sides.

Auscultation (Listening to Breath Sounds)

Using a stethoscope, the physiotherapist listens to breath sounds over all areas of both lungs. Abnormal sounds such as crackles (indicating secretions or fluid), wheeze (airway narrowing), or absent breath sounds (indicating collapse or consolidation) guide the treatment approach.

Review of Chest Imaging

Chest X-rays and CT scans are reviewed to identify areas of collapse, consolidation, pleural effusion, or pneumothorax that may influence positioning and treatment choices.

Ventilator Assessment

For mechanically ventilated patients, the physiotherapist reviews the ventilator parameters — including tidal volume, respiratory rate, PEEP (positive end-expiratory pressure), and FiO₂ — and monitors how these change during and after treatment.

Physical Assessment

The physical assessment evaluates the patient's musculoskeletal function, strength, and capacity for movement. In the ICU, this must be adapted to the patient's level of consciousness and ability to cooperate.

Level of Consciousness and Sedation

The physiotherapist uses validated tools such as the Richmond Agitation-Sedation Scale (RASS) to determine the patient's level of sedation or agitation. This directly determines what level of active participation is possible.

Muscle Strength Testing

When patients are awake and able to cooperate, muscle strength is formally assessed using the Medical Research Council (MRC) sum score. This tests the strength of six muscle groups on each side of the body (wrist extensors, elbow flexors, shoulder abductors, ankle dorsiflexors, knee extensors, and hip flexors), each graded on a scale of 0 to 5. A total score below 48 out of 60 indicates ICU-acquired weakness.

Range of Motion

All major joints are assessed for their available range of motion — both actively (patient moves independently) and passively (therapist moves the limb). This identifies any stiffness, contractures, or painful limitations that need to be addressed.

Functional Assessments

As patients improve, more functional tests are used to guide progression of the rehabilitation programme. Commonly used tools include:

• Functional Status Score for the ICU (FSS-ICU): Assesses rolling, sitting up, transferring from bed to chair, standing, and walking.
• Chelsea Critical Care Physical Assessment (CPAx): Evaluates respiratory function, coughing, moving in bed, sitting balance, standing, stepping, and grip strength.
• Six-Minute Walk Test (6MWT): Used in patients who are well enough to walk, to assess functional exercise capacity.

Cognitive and Communication Assessment

ICU delirium is common and significantly impacts the ability to engage in physiotherapy. The physiotherapist screens for delirium using tools such as the Confusion Assessment Method for the ICU (CAM-ICU) and adjusts the rehabilitation approach accordingly.

For patients who cannot speak — due to intubation or tracheostomy — the physiotherapist establishes simple communication methods (e.g., yes/no hand signals or eye blinks) to enable some level of patient participation and consent.

Goal Setting and Treatment Planning

Once the assessment is complete, the physiotherapist documents their findings and sets short-term and longer-term rehabilitation goals in collaboration with the patient (where possible), the family, and the wider ICU team. Goals are:

• Specific and measurable (e.g., "patient to sit over edge of bed independently by Day 5")
• Realistic given the patient's current condition and trajectory
• Meaningful to the patient — anchored to what they want to be able to do when they leave hospital

The treatment plan is reassessed at every session and adjusted as the patient's condition changes. Progress in the ICU is rarely linear — there will be good days and setbacks — and the physiotherapist must be ready to scale the programme up or down accordingly.

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ICU physiotherapy assessment is a complex clinical skill that requires both technical knowledge and sound clinical judgement. It is the essential first step in ensuring that every patient receives rehabilitation that is safe, appropriate, and effective. If you have questions about physiotherapy for a family member in intensive care, or need post-ICU rehabilitation support, our team is available to help.

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