Upper Limb Rehab in the ICU

Written by:

Carla Vidal-Hall, OT

'24/'25 VHSF Fellow

South Africa

The intensive care unit is the department of a hospital in which patients who are dangerously ill are kept under constant observation. The patient’s heart rate, blood pressure, oxygen saturation, and temperature are constantly monitored. Patients are often dependent on mechanical ventilation or supplemental oxygen. Sedation may be used as necessary, which means that some patients may be unconscious. Every patient typically has their own nurse.

Life-threatening conditions most commonly admitted to the intensive care unit include pulmonary conditions requiring ventilation, cardiac disorders needing close monitoring, post-surgical complications with cardio-pulmonary compromise, systemic infections, and neurological conditions such as CVAs, TBI, and SCIs (Clark, 2017).

Long ICU stay (especially under mechanical ventilation) negatively affects upper limb function. Individuals hospitalized in the ICU present with decreased upper limb function at discharge and at 6 months follow-up compared with those not admitted to the ICU (de Carvalho et al., 2023).

Conditions causing upper limb dysfunction in the ICU include fractures, dislocations, traumatic amputations, peripheral nerve injuries, traumatic brain injuries, CVA’s, spinal cord injuries, ICU-acquired weakness, and systemic conditions causing generalized oedema.

Upper limb dysfunction is associated with lengthened ICU stay, longer periods of hospitalization, and marginally increased long-term, self-reported disability when compared to admissions without upper limb injuries (Zeelenberg et al., 2022).

Occupational therapists thus have a role to play in treating upper limb dysfunction in the ICU.

I have identified 5 phases of general rehab in the ICU based on the patient’s mental status and mobility.

I will describe the role of the OT in general and specifically upper limb rehab for each of these 5 phases.

Phase 1 - The Patient is Ventilated and Sedated

In this phase, the patient is not conscious. We try to regulate stimulation from visitors, noise, lights etc., so that the patient can recover (especially if they are on neuro-protection). We can use light to simulate normal day-night cycles. Adapting the environment with changes in light therapy might prevent delirium by improving sleep  (Bryczkowski et al., 2014).

Patients are unable to maintain their own range of motion, shift their body weight to prevent pressure sores and keep their muscles conditioned. Our role is to position the patient’s joints so that deformities and pressure sores are prevented. This can be accomplished by soft positioning the hand in an anti-deformity position with rolled towels or by splinting (resting hand splints). We also help to maintain the range of motion of the joints and complete circulation drills. Oedema management includes pressure garments, mobilizing massage, elevation and vibration.

Phase 2 - The Patient is being weaned off Ventilation and Sedation (Starting to wake)

As the sedatives are gradually reduced, the patient starts to wake. We have a role in grading the stimulation (natural light, neural stimulation, sensory stimulation etc.) so that the patient wakes gradually.

Receiving Occupational therapy at the earliest stage of critical illness (while still on the ventilator) is safe and produces better functional outcomes at discharge (Deng et al., 2020).

30-60% of those admitted to the ICU develop delirium, of which 80% are mechanically ventilated (Antoni et al., n.d.). Occupational therapists manage delirium by altering environmental factors of the room (light, temperature, sound), by changing the patient’s position and enabling participation in functional tasks, by promoting normal sleep-wake cycles, and through cognitive stimulation (Falkenstein et al., 2020).

Once the patient is able to follow motor commands, we start with neuromuscular rehabilitation (joint compressions, place and hold). We also initiate active circulatory drills and cardio-pulmonary rehab (upper limb elevations combined with deep breathing).

Phase 3 - Initial functional strengthening commences

Once the patient has a bit of cardio-pulmonary endurance, the first functional movement that we work on is elbow flexion to bring the hand to the face. Next, we work on proximal strengthening (shoulder scaption). Occupational therapy has a critical role in preventing ICU-acquired weakness (proximal weakness) by ensuring early mobilization (Schweickert et al., 2009). After that we prioritize grip strengthening, coordination and prehension.

Phase 4 - Initial ADL’s are introduced

Once the patient has regained some upper limb function, we introduce some ADLs that are realistic to engage in in the ICU setting.

Once the speech therapist has assessed the patient for aspiration risk, we start to work towards independence in feeding. We might do this by adapting the task, the environment, or by addressing body structures and functions through functional exercises. Other activities that are important initially include completing the patient’s personal morning routine, brushing hair and brushing teeth. At this phase we usually sit the patient up in bed or complete the activity at the edge of the bed. One of the goals of occupational therapy in the ICU is to increase tolerance to activity. For example, increasing the patients time that they tolerate sitting up in bed before becoming dizzy (Schweickert et al., 2009).

Phase 5 - Preparing the patient for transfer to High Care/the surgical ward

In this last phase, we prepare the patient so that they can be discharged to high care or the surgical ward, where they are monitored less and are expected to be more independent. In this phase, we focus on safe transfers and toileting. We work towards activity tolerance and endurance by engaging the patients in activities where they have to sit or stand for longer periods of time (sorting their drawer, having breakfast at the edge of the bed). We have to adapt transfers and activities so that the patient continues to adhere to precautions for upper limb fractures/injuries.

In summary, we can see that hand therapy is not the only field we need knowledge of when working in the ICU.

However, many patients in the ICU can benefit greatly from hand therapy services, which can improve their outcomes and shorten their hospital stay.

Reference List

Clark, K. (2017). Intensive care unit. In H. Smith-Gabai & S. E. Holm (Eds.), Occupational therapy in acute care (2nd ed., Chapter 9). AOTA Press.

de Carvalho, D. A., Malaguti, C., Cabral, L. F., Oliveira, C. C., Annoni, R., & José, A. (2023). Upper limb function of individuals hospitalized in intensive care: A 6-month cohort study. Heart & Lung, 57, 283–289. https://doi.org/10.1016/j.hrtlng.2022.10.011

Zeelenberg, M. L., Den Hartog, D., Halvachizadeh, S., Pape, H.-C., Verhofstad, M. H. J., & Van Lieshout, E. M. M. (2022). The impact of upper-extremity injuries on polytrauma patients at a level 1 trauma center. Journal of Shoulder and Elbow Surgery, 31(5), 914–922. https://doi.org/10.1016/j.jse.2021.10.005

Bryczkowski, S. B., Lopreiato, M. C., Yonclas, P. P., Sacca, J. J., & Mosenthal, A. C. (2014). Delirium prevention program in the surgical intensive care unit improved the outcomes of older adults. Journal of Surgical Research, 190(1), 280–288. https://doi.org/10.1016/j.jss.2014.02.044

Deng, L.-X., Cao, L., Zhang, L.-N., Peng, X.-B., & Zhang, L. (2020). Non-pharmacological interventions to reduce the incidence and duration of delirium in critically ill patients: A systematic review and network meta-analysis. Journal of Critical Care, 60, 241–248. https://doi.org/10.1016/j.jcrc.2020.08.019

Antoni, R., Gaus, G., Greaney, K., Ortiz-Brazak, M., Herge, E. A., & Sinko, R. (n.d.). Delirium in the acute care setting: Occupational therapy’s role in delirium management and prevention [Unpublished manuscript]. Thomas Jefferson University.

Falkenstein, B. A., Skalowski, C. K., Lodwase, K. D., Moore, M., Olowski, B. F., & Rojavin, Y. (2020). The economic and clinical impact of an early mobility program in the trauma intensive care unit: A quality improvement project. Journal of Trauma Nursing, 27(1), 29–36. https://doi.org/10.1097/JTN.0000000000000479

Schweickert, W. D., Pohlman, M. C., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L., Spears, L., Miller, M., Franczyk, M., Deprizio, D., Schmidt, G. A., Bowman, A., Barr, R., McCallister, K. E., Hall, J. B., & Kress, J. P. (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial. The Lancet, 373(9678), 1874–1882. https://doi.org/10.1016/S0140-6736(09)60658-9