Post intensive care syndrome: recovering after intensive care

How long does it take to recover after intensive care?

Months, and for a fair number of people more than a year. The NHS says many people who leave an intensive care unit go on to recover well, and in the same breath lists what can hang about: weakness and stiffness, extreme tiredness and no energy, a lost appetite and lost weight, broken sleep, depression, anxiety or post-traumatic stress, and trouble thinking clearly or remembering things. It puts the timescale at several months and says to get medical advice if any of it is persistent. Post intensive care syndrome is the name that pattern goes under.

The far end of the range has been measured properly in one group. Herridge and colleagues (2011) followed 109 people who survived acute respiratory distress syndrome, a severe lung injury, at 3, 6 and 12 months and then once a year out to five years after they left intensive care. At five years the median distance they covered in a six minute walk was 436 meters, 76 percent of what would be predicted for them, and their physical quality of life score averaged 41 where the matched population average is 50. Younger patients came back faster than older ones, and neither group reached predicted normal by five years.

Read that cohort for what it was. These were survivors of one severe lung condition, and they are not a forecast for somebody who spent two nights in intensive care after an operation. What the study is good for is the shape of the thing: improvement still going on years later, and a tail that does not fully close.

The first signs of progress are nearly always in what you can do rather than in what you can lift. Getting off the toilet without hauling on something. Washing your own hair. Staying awake through a whole visit instead of sleeping through the second half of it.

One flat week is ordinary and tells you nothing. A month with nothing moving, or ground actually lost, is information, and it belongs with the review further down this page rather than with another month of patience.

Why you are this weak: ICU-acquired weakness is not the same as being out of condition

A week lying on a general ward costs you fitness. A critical illness can go further than that and damage the nerves and the muscle themselves, which is why this weakness behaves differently and why the word deconditioning does not cover it.

Critical illness polyneuropathy affects the nerves running out to the muscles, and critical illness myopathy affects the muscle itself; together they are usually called ICU-acquired weakness. In the unit they announce themselves as weakness and as difficulty getting off the ventilator. The changes described in the tissue are degeneration of nerve fibers, loss of myosin, which is the protein a muscle uses to pull, and death of muscle cells, and the diagnosis rests on clinical examination, electrical testing of nerve and muscle, and sometimes a muscle biopsy (Latronico and Bolton, 2011). Not all of it is damage to the structure: the same paper describes functional changes too, nerves and muscle that stop carrying the electrical signal properly for a while, with muscle weakness that reverses, so not all of this weakness is permanent.

The same paper is blunt about what follows. These problems lengthen time on the ventilator and time in hospital, raise the risk of dying in hospital, and leave lasting disability in people who survive. On the other side of the ledger, the authors suggest that rehabilitation started early, in the unit itself, might improve how well people function and how independent they are afterward, and might is their word rather than ours.

This page gives you no figure for how common it is, and that is deliberate. The percentages in circulation come from studies that defined the problem differently in different groups of patients, and we could not trace any of them back to a single piece of work we had read, so we are not passing one on. What you lose by not having a number is nothing you could act on.

What all that means in practice comes in two halves, pointing in opposite directions. Strength returning from nerve and muscle damage returns slowly, so slow is expected and is not evidence you are doing the program wrong. The other half is the next section: weakness that is getting worse rather than better is not this, and it is not something to train through. If you were on a general ward rather than in intensive care and want the ordinary loss of condition explained, recovering strength after a hospital stay is that page.

What is post intensive care syndrome, and what does it not mean?

It is an umbrella term. A group of stakeholders from the organizations that look after intensive care survivors agreed it at a Society of Critical Care Medicine conference, as a way of naming new or worsening problems in physical, cognitive or mental health that arise after a critical illness and carry on past the hospital stay (Needham and colleagues, 2012). A later review of the field is blunter still: post intensive care syndrome is not a medical diagnosis but a concept for raising awareness of what happens after intensive care (Hiser and colleagues, 2023). Nobody is going to hand you a test result for it.

How common the pattern is has been measured, and the way it was measured matters. A Dutch study put the same set of questions to 2,345 people twice, once about their health before intensive care and once a year afterward. New physical, mental health or thinking problems at the one year mark were reported by 58 percent of those admitted for a medical reason, 64 percent of those admitted after urgent surgery and 43 percent of those admitted after a planned operation (Geense and colleagues, 2021).

How that first set of answers was collected differs between those groups, and it is worth knowing: people coming in for a planned operation filled the questionnaire in before admission, while those admitted as an emergency, or their relatives, were asked afterward to describe how they had been (Hiser and colleagues, 2023). A remembered baseline is not a measured one. The same review points out that the physical side was measured with a questionnaire that had never been validated, so read these figures as a sign that the problem is common. They are not a precise rate.

Now the half that matters more, because it is the half that gets people into trouble. An umbrella that covers weakness, tiredness, breathlessness, poor memory and low mood will cheerfully absorb a blood clot, a chest infection, a low blood count or a stroke, because every one of those arrives as weakness and tiredness too.

The label is not an explanation for a new symptom, and it is not a diagnosis you can give yourself. It is also not a measure of how hard you are trying, which is worth saying plainly to anybody who has been told to stay positive.

The weakness that needs a doctor today, not exercise

The particular trap on this page is that you have a license. You were in intensive care, so being weak and exhausted is explained in advance, and an explanation that good will swallow almost anything.

Two things separate loss of strength from a symptom: the direction it is traveling in, and what it has brought with it. Weakness left by a critical illness eases slowly, and eases a little further on a day you have eaten and slept. Weakness that is worse this week than last week, or that turned up over an afternoon, or that arrived alongside something new, is a symptom and goes to a doctor before it goes into a program.

Three patterns on this page are not ever filed under recovery. Anything on one side only, meaning an arm or leg that has gone weak or numb down one side, a face that droops, or speech that slurs, means calling emergency services even if it has already passed off. A foot that drags, catches on the ground or slaps down when you walk needs medical advice the same day. And sudden confusion is an emergency at home, while the quiet version of the same thing, somebody going withdrawn, slow to answer and off their food over hours or days, needs advice the same day; both lines are in the warning list at the foot of this page with what to do.

Never stop or change a prescribed medicine on your own. If you have become weak, dizzy or muddled since you came home, the list you came home with is worth going through with your doctor or pharmacist, and that is a conversation, not a decision you make at the kitchen table.

The fuller list of treatable things that get mistaken for loss of condition, the clot, the infection, the low blood count, the new medicine, the blood pressure that drops when you stand, the fluid the heart is not keeping up with, is written out on the hospital stay page, and each of them has its own line in the warning list below. The medicines are the exception, because there is no single symptom to watch for: they are a conversation with your doctor or pharmacist rather than a warning sign. If your admission included an operation, the signs that a repair or a new joint has given way are on that page too, and they are worth reading, because from the inside they look exactly like a bad week. The wound, breastbone, scar and tube signs that belong to somebody just home from critical care are in the warning list at the foot of this page.

Swallowing, voice and breathing after a breathing tube

A breathing tube passes between the vocal cords, and weeks of not swallowing and not speaking sit on top of that. NICE's own pre-discharge assessment list for people who have been critically ill names trouble swallowing and difficulty speaking among the physical problems to look for, so this is expected territory rather than an odd thing to bring up.

We give you no figure for how long a changed voice or a changed swallow lasts, because we have no source we have read that gives one for this group. What there is instead is a route, and it is a fast one. Coughing or choking on food or drink, food that sticks in your throat or chest, food or drink that comes back up, a voice that sounds wet or gurgly after you swallow, or being short of breath after eating or drinking all go to somebody today rather than into a plan you work out for yourself at home, and it is worth asking whether your swallowing should be assessed by a speech and language therapist. The same day line is in the warning list below with the two faster routes inside it: swallowing that goes wrong suddenly belongs with the stroke line and emergency services, and anybody choking who cannot cough, speak or breathe needs emergency services now. Cutting food smaller, eating alone so nobody sees it, and quietly giving up on drinks all hide the problem instead of fixing it.

A tracheostomy changes the picture a little, because that tube breathes below the voice box rather than through it. If you came home with one, or with a healing hole in your neck where one was, the NHS asks you to get urgent advice if your breathing turns noisy by day or at night, including snoring that is new, if your voice stays hoarse or weak for more than a week, if swallowing is a problem, if you cough or are sick after eating or drinking, or if the area is painful, raised or uncomfortable. That list is less mild than it sounds. The windpipe can narrow where a tube and its cuff sat, and what that looks like from the outside is breathing that gets noisier and harder rather than easier, which on this page of all pages is the thing most likely to be put down to lack of fitness. It belongs with the surgical or ear, nose and throat team rather than with a training plan.

Any bleeding from a tracheostomy, or from the hole where one was, needs emergency services, and so does any difficulty breathing. Both have their own lines in the warning list below.

After an operation in the chest or the neck, a hoarse, weak or breathy voice can also mean a nerve to the voice box was bruised on the way past, and that matters beyond the sound of it, because the same nerve helps close the airway when you swallow. So raise the voice and the swallowing together, in the same conversation.

Breathlessness is the other one that follows a breathing tube around, and there is a useful detail in the five year study. Lung function testing in those survivors came back normal to near normal, and they still walked only 76 percent of their predicted distance in six minutes (Herridge and colleagues, 2011). So the limit on what they could do was not simply a lung limit, which cuts both ways for a reader: being breathless on effort does not mean your lungs are ruined, and it does not mean you are merely unfit either.

New breathlessness, or breathlessness that is getting worse, is a different question from breathlessness that is slowly improving. The warning list below gives it several routes. The emergencies on it are a clot in the lungs, severe difficulty breathing where you are gasping or cannot get your words out or your lips or skin turn very pale, blue or gray, and breathlessness with pain spreading to your arm, neck, jaw, back or stomach even when your chest itself does not hurt. None of them is a reason to push harder. For breathing technique alongside the strength work, breathing exercises for long-term chest conditions covers what to practice, and cardiac rehab covers the same ground after a heart problem.

Memory, mood and the nights

This is not the soft part of the page. NICE puts the physical and the non-physical into the same assessment, done at the same time by the same service, which tells you how it is meant to be treated.

The NHS names sleep problems, depression, anxiety and post-traumatic stress, along with trouble thinking clearly and being forgetful, among the things that can last several months after intensive care. NICE's own list of non-physical problems goes further into the specifics: a pounding heart, irritability and sweating; feeling detached from yourself or from what is around you; avoiding reminders; tearfulness and pulling away from people; nightmares, delusions, hallucinations and flashbacks; losing memories, losing the thread, finding it hard to put things in order or organize anything, confusion, apathy, saying things you would not have said, and not seeing any of it in yourself; low self-esteem, a changed sense of your own body, and trouble in your closest relationships.

Four of those are worth knowing by name, because NICE treats them as markers that someone needs rehabilitation rather than as ordinary distress. Nightmares that keep coming back, especially when the person has started trying to stay awake to avoid them. Memories of what happened that push their way in uninvited. New anxiety or panic attacks that keep happening. And not wanting to talk about the illness, or changing the subject fast when it comes up.

When somebody asks how you are getting on, the legs get reported, because the legs are the acceptable answer. The memory, the nights and the mood get left out, and what is left out does not get a plan.

So say it anyway, in the same appointment, in the same sentence as the stairs. This page offers no treatment for any of it, because that belongs to whoever assesses you. What it can tell you is that it is part of a recognized pattern, that it is not a sign of weak character, and that the route for it is the route you already have.

One part of this does not wait for an appointment. Thoughts of suicide, or of harming yourself, have their own line in the warning list below, and they need help the same day even if you have no plan to act on them.

Who gets rehabilitation, when it starts, and what the review should be

In the UK there is a written answer to this, which is useful even where you live somewhere else, because it tells you what to ask for. NICE clinical guideline CG83 covers rehabilitation after critical illness in adults, and the quality standard QS158 sets out what a service is expected to deliver. CG83 was published in 2009 and written for England, so it is both old and local, and that is worth holding in mind.

It starts in the unit. CG83 asks for a short clinical assessment during the critical care stay, as early as is clinically possible, to work out who is at risk of physical and non-physical problems afterward. For somebody in that at-risk group, rehabilitation is meant to begin as early as is clinically possible, and NICE describes it as including a look through past and current medicines, support with nutrition, and an individual structured rehabilitation program with frequent reviews.

The at-risk list is how you find out whether any of this was written about you. On the physical side NICE names being unable to get out of bed without help; a critical care stay expected to be long; an obvious significant physical or neurological injury; not being able to think well enough to carry on exercising independently; not being able to breathe for yourself on 35 percent oxygen or less; breathing or mobility problems that were already there beforehand; and not being able to walk independently even a short distance. On the non-physical side it names the four markers in the section above.

Three things are meant to be handed to you, and they are the three most often missing. The contact details of the professional coordinating your rehabilitation, given once when you leave critical care and again when you leave hospital. A functional assessment before you go home, covering both sides of this: pain, fatigue and breathlessness; weakness and whether you can sit up, rise to standing and walk; swallowing; bladder and bowel control; vision, hearing and sensation; speech and writing; the practical list of equipment, transport, housing, money, work and getting out; and alongside all of that anxiety, low mood, post-traumatic symptoms, and the behavioral, thinking and social problems. And a review 2 to 3 months after you leave critical care, face to face, in hospital or in the community, repeating that same assessment, done by somebody who knows what happened to you in critical care and what your rehabilitation plan was.

That review is a gate rather than a courtesy call, and this is the single most useful sentence on the page. CG83 says that if you appear to be recovering more slowly than the goals you agreed, or something unexpected has turned up, that is where a referral to a rehabilitation or specialist service is made. It also asks for support for someone who is not getting better as fast as they expected. NICE goes on to say that a structured, supported self-directed rehabilitation manual running at least 6 weeks after critical care may be offered, coordinated throughout by a suitably skilled professional, and consider is the word it uses, so that is something to ask about rather than something you are owed.

QS158 is the other half, and it is the one to quote to a service rather than to a clinician. It has four quality statements: rehabilitation goals; transfer from critical care to a general ward; information on discharge from hospital; and follow-up after critical care discharge. It covers adults with rehabilitation needs after critical illness that required level 2 or level 3 critical care, and it leaves out conditions that have standards of their own, such as head injury, heart attack and stroke. It applies in England and Wales.

Outside the UK the words change and so does who pays. In the United States, Canada, Australia, New Zealand and across Europe, critical care follow-up is arranged differently from one hospital and one insurer to the next, and some units run a follow-up clinic while others have nothing of the sort. We are not going to tell you what you qualify for, because any answer would be wrong somewhere. What travels is the asking: who is coordinating my rehabilitation, when am I being reviewed, and what happens if I am behind.

What to ask for, and what to do if nobody has been in touch

Start with the thing everybody gets wrong. Leaving hospital means you no longer needed a hospital bed. It is not a clearance to start exercising, and it is not a set of limits, and who sets your limits and how to find them is worked through step by step on the hospital stay page.

Then there is a short list worth taking to any appointment, in writing, because people come out of critical illness tired and nothing spoken sticks.

• A name and a phone number for whoever is coordinating your rehabilitation.
• Whether the assessment before discharge was done, and what it found.
• The date of your 2 to 3 month review and who is doing it.
• A referral to rehabilitation, in those words, if you are behind the goals you agreed.
• Whether there is a self-directed rehabilitation manual you can be given.
• Whether the unit you were in runs a follow-up clinic.
• The memory, sleep and mood side, raised in the same conversation as the legs.

If nobody has been in touch, do not read the silence as a clearance. It usually means a form did not travel, and the review is the gate a referral comes through, so missing it quietly costs you the referral. In the UK, if the two month mark passes with nothing booked, ring the number on your discharge letter, or your own doctor's practice, and ask when the review is happening. Elsewhere, ask the unit whether it has a follow-up clinic and ask your own doctor for a rehabilitation referral.

Do not save a new symptom for the review. Anything new, anything suddenly worse, and anything in the warning list below goes now, at the speed that list sets. For practical help at home, and for what the rehabilitation service is called in your country, the hospital stay page covers both.

How to use this program

Start at stage 1 whatever you could do before you were admitted. The commonest mistake in the first fortnight is starting where you used to be rather than where you are, and the second commonest is doing a good day's worth of exercise on a good day and nothing for three days afterward. If even the seated work is beyond you today, do less of it rather than none: one or two of the exercises, once, is a start. A whole week where stage 1 is still beyond you is information for your doctor or physio rather than a reason to push harder, and it has its own line at the foot of the warning list.

Each exercise page gives a typical starting dose, and in the first weeks the bottom of that range is the useful version. The pages do not all mean the same thing by their number, so it is worth reading which.

Where a page says several times a day, as the breathing, the ankle pumps, the quad sets and the grip squeeze do, that number belongs to each go. Where it gives a number once a day, as the knee extension, the band row and the chair stands do, that is the whole day, so split it across your two or three goes rather than repeating it in each one. What your legs feel by bedtime is the total. Stage 2 is one go a day, so there the page's number is the session.

If a physio is setting your numbers, theirs replace these. If nobody is, that is not a reason to wait: take the bottom of the range, let the next morning be the adjuster, and ring the number on your discharge letter or your own doctor's practice to ask for a rehabilitation referral and for someone to set the numbers properly. What to ask for is in the section above.

Soreness for a day or two after a new exercise is normal. Sharp pain during an exercise means stop that exercise for today, and a joint that is more painful or swollen the next day means the load was too much for now, so do less next time rather than stopping altogether. A calf or thigh that is swollen, warm or red is not ordinary soreness and is on the warning list below.

While you exercise, stop straight away if you get chest pain or pressure, feel dizzy or faint, notice a racing or irregular heartbeat, or become far more out of breath than the effort should cause. What to do next is in the warning list below. Breathe steadily through every repetition rather than holding your breath, which matters most if you have high blood pressure. If you have a healing wound on your tummy or your chest, that sentence is doing a second job: holding your breath and straining pushes on the repair from the inside, and that is how a wound comes apart early on and how a bulge appears at a scar later. Breathe out on the effort, and treat an exercise you can only manage by straining as too much for now.

Read the warning list at the foot of this page before you start rather than after something has gone wrong. Its first group is the one that needs emergency services rather than a phone call, and most of what is on the list looks, from the inside, exactly like being weak and tired after critical care.

If somebody is helping you, give them that list too. NICE's own account of what follows critical illness includes not seeing these changes in yourself, so the person in the room is often the first to notice you go gray, grip the counter harder or stop answering, and there is a section further down this page written for them.

If you have fallen in the past year, feel unsteady on your feet, or take medicines that make you dizzy, keep a hand on the counter throughout, practice only when someone else is at home, and ask your doctor or physio about a falls check. The balance and falls prevention program is the other half of this work, not a replacement for it.

If you have fallen in the past year, feel unsteady or take medicines that make you dizzy, and nobody can be there, stay with stage 1 until somebody can, or until a physio or doctor has seen you. That is not the same as doing nothing, because the seated work needs nobody in the room. The one exception inside stage 1 is standing up from the chair with the armrests, whose own page asks a reader who has fallen before to have somebody nearby for it.

If you live alone, that rule still stands, so plan around it rather than ignoring it. Do the standing and balance exercises at your physio appointments or a falls prevention class rather than by yourself, keep to the seated work of stage 1 when you are on your own, and ask your physio which of the standing exercises you may do alone. Keep your phone in a pocket rather than in another room, so you can reach it from the floor, and ask about an alarm you wear.

If you do fall and cannot get up, or you think you may have hurt your head, neck, back or hip, stay where you are, keep warm and call emergency services, or get someone to call for you. Do not let anyone haul you up first. That line and the rest of the fall routes, including what to do if you got up fine and only hurt later, are in the warning signs below.

Tiredness and weakness are not the same problem and do not answer to the same handling. The pacing side of it is covered on the hospital stay page.

Four situations change the plan. If your admission included an operation, your surgical team's plan replaces this one for as long as it runs, and the wound, clot and repair warning signs matter more than any exercise detail on this page. If the operation was done in a different hospital from the one that sent you home, which happens often after a critical illness, the team who operated is still the one to ask about the wound, about what the repair will take and about what you may lift, push or pull. Their details are on your operation note or your discharge letter, and your own doctor's practice can get hold of them. This page sets no lifting or weight limit of its own, because the limit depends on which operation you had and on the surgeon who did it, and no page can read it off for you.

This page is written for adults, so a child or young person who has been in intensive care follows the plan from their own team, and everything here is a question for that team first. If you are pregnant or recently gave birth, check with your midwife, doctor or physio before you start. And if you came home using oxygen, ask whoever set it up before you begin the standing work.

Heart or chest surgery adds one more. If your chest was opened through the breastbone, which is how most heart surgery and some other chest operations are done, leave out the band row and the wall push-up until your surgeon says the breastbone has healed enough for loaded pushing, pulling and lifting. Pushing yourself up out of a chair with your hands belongs on the same list, which is what the armrest version in stage 1 asks for, so ask your team about that one too. If they have asked you to keep your hands off the armrests, stand up with your arms held out in front of you instead. If the breastbone clicks, grinds, shifts or feels as if it is moving while you do it, stop, and contact your surgical team the same day.

If you came home with a frame or crutches, say that your chest was opened when you ask about the exercises, because leaning and pushing through the arms on a walking aid loads the breastbone as well, and your team may want to change the aid rather than the exercise. If your chest was opened from the side instead, between the ribs, the breastbone rules are not yours, but the same question is: ask the team who operated what the arm on that side may push, pull and lift, and leave out anything that pulls at the wound until they have told you. The breastbone rules are set out in full on the cardiac rehab page.

And one more, if you came home with a tracheostomy tube still in place. Ask the team who look after it before you start the breathing exercise, and keep to the plan they gave you for cleaning it, for suctioning and for what to do if it blocks. Noisy breathing, a hoarse or weak voice, trouble swallowing and pain around the tube are in the warning list below, and any bleeding from it, or any difficulty breathing, needs emergency services.

The two stages below stop at walking about indoors. Stairs, load and getting back out of the house are stage 3 of the hospital stay program, which is where to go next, and the exercises carry on in the same order.

The exercise program

The exercises below carry their own stop signs and precautions. Open the line under an exercise and read them before you try it.

For the person helping

You may well be the one reading this, because the person you are reading it for is too tired to. Two changes are worth more than anything else you will do, and both are things only you can see.

The first is confusion, and it has two faces. Somebody who suddenly goes muddled, much drowsier, unable to follow what is being said or who is seeing things that are not there is an emergency at home, whatever has caused it. The quiet version is the one that gets missed: withdrawing, answering slowly, moving about less, losing interest in food, over hours or days rather than weeks. That one needs advice the same day, and both lines are in the warning list at the foot of this page.

The second is the night side. If they have started trying to stay awake to avoid nightmares, if memories of the unit are pushing their way in, if panic has turned up and keeps turning up, or if they change the subject fast whenever the illness comes near, those are on NICE's own list of markers that somebody needs rehabilitation rather than ordinary distress. Report them the way you would report a swollen calf.

Then there is you. The five year follow-up of those lung injury survivors reported that physical and psychological problems developed or carried on in the family caregivers as well as in the patients, out to five years (Herridge and colleagues, 2011). Broken sleep, dread, going over the weeks in the unit again and again: that is part of the same picture, it has the same route through your own doctor, and asking early about carer support where you live is the sensible thing to do.

The practical half of helping, how to set the chair up, how to be present without taking the work away, and getting the medicine list reviewed, is on the hospital stay page.

When to see a physio or doctor

See a physio or your doctor if nothing has moved over two or three weeks, if the exercises in stage 1 are beyond you, if you are not sure which stage you belong in, or if you are behind the goals somebody set with you. In the UK, add one more trigger: the two month mark arriving with no review booked. A physical therapist (physiotherapist) can measure where you are now, which is far more useful before you start than after a disappointing month.

Check with your doctor before you begin if you have a heart or lung condition, blood pressure that is not under control, or if you came home on oxygen. If you were given a rehabilitation plan or a referral when you left, use that rather than this page, and take this page along if it helps the conversation.

Some things need help faster than an appointment, from a call to emergency services down to a visit in the next few days. They are all in the warning signs below, each with its own timing. Read that list before you start the program and again a fortnight later, because the items on it are not the ones you would think to watch for.

For physiotherapists

Treat ICU-acquired weakness as a diagnosis rather than as the severe end of deconditioning. Critical illness polyneuropathy and critical illness myopathy present as weakness and as failure to wean, the structural picture is axonal degeneration, myosin loss and muscle necrosis, and confirmation rests on clinical, electrophysiological and biopsy grounds; the same paper reports prolonged ventilation, longer hospitalization, higher hospital mortality and chronic disability in survivors, suggests glycemic control might reduce severity, and suggests early rehabilitation in the unit might improve functional recovery and independence (Latronico and Bolton, 2011). We state no prevalence figure anywhere on this page, because the figures in circulation rest on different definitions in different populations and none could be traced to a primary source here.

On in-unit dose, TEAM is the trial to have read. It is an Australian and New Zealand trial, with registered sites in the UK, Ireland and Germany as well (NCT03133377).

750 ventilated adults were randomized to increased early mobilization, through sedation minimization and daily physiotherapy, or to usual care. Mean daily active mobilization reached 20.8 minutes against 8.8, and the median number of days alive and out of hospital at 180 days was 143 against 145, a difference of 2.0 days fewer in the intervention group with a confidence interval running from 10 days fewer to 6 days more. Death by day 180 was 22.5 percent against 19.5 percent, serious adverse events occurred in 7 patients against 1, and adverse events potentially attributable to mobilization, meaning arrhythmias, altered blood pressure and desaturation, occurred in 9.2 percent against 4.1 percent (Hodgson and colleagues, 2022). More and earlier is therefore not established as better inside the unit, and the trial says nothing either way about what you do after discharge.

For the English pathway, CG83 recommendations 1.23 to 1.25 are the ones to quote in a letter. The 2 to 3 month functional reassessment is a referral gate, not a check-in call: slower recovery than the agreed rehabilitation goals, or unanticipated morbidity, is what triggers onward referral, and the reassessment is meant to repeat the pre-discharge dimensions so there is something to compare. QS158 is the service-level lever in England and Wales, with its four statements on rehabilitation goals, transfer to a general ward, discharge information and follow-up after critical care.

Measure the non-ventilatory limitation rather than assuming the lungs. In the five year ARDS cohort, pulmonary function was normal to near normal while the median six minute walk sat at 76 percent of predicted and the physical component summary at 41 against a norm of 50 (Herridge and colleagues, 2011). The six-minute walk test, the 30-second chair stand test and the Timed Up and Go each carry their own norms and are repeatable in a living room.

Screen the non-physical dimension at every contact, because a program that stops at the legs is the usual way this goes wrong. CG83 puts the physical and non-physical lists into one assessment for a reason, and the four at-risk markers it names, recurrent nightmares with sleep avoidance, intrusive memories, new recurrent anxiety or panic, and reluctance to discuss the illness, are askable in under a minute. Swallowing belongs in the same minute: it is on CG83's physical list, and the page's same-day dysphagia route is written for a patient who has quietly started avoiding drinks.

Common questions

References

1. National Institute for Health and Care Excellence. Rehabilitation after critical illness in adults. Clinical guideline CG83. Published 25 March 2009. https://www.nice.org.uk/guidance/cg83
2. National Institute for Health and Care Excellence. Rehabilitation after critical illness in adults. Quality standard QS158. Published 7 September 2017. https://www.nice.org.uk/guidance/qs158
3. NHS. Intensive care. Page last reviewed 24 February 2023. https://www.nhs.uk/conditions/intensive-care/
4. Latronico N, Bolton CF. Critical illness polyneuropathy and myopathy: a major cause of muscle weakness and paralysis. Lancet Neurology. 2011;10(10):931-941. https://doi.org/10.1016/S1474-4422(11)70178-8
5. Herridge MS, Tansey CM, Matte A, et al. Functional disability 5 years after acute respiratory distress syndrome. New England Journal of Medicine. 2011;364(14):1293-1304. https://doi.org/10.1056/NEJMoa1011802
6. Needham DM, Davidson J, Cohen H, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference. Critical Care Medicine. 2012;40(2):502-509. https://doi.org/10.1097/CCM.0b013e318232da75
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16. NHS. Pneumonia. Page last reviewed 17 July 2026. https://www.nhs.uk/conditions/pneumonia/
17. NHS. Sepsis. Page last reviewed 14 May 2026. https://www.nhs.uk/conditions/sepsis/
18. NHS. Dysphagia (swallowing problems). Page last reviewed 26 October 2026. https://www.nhs.uk/symptoms/swallowing-problems-dysphagia/
19. NHS. Tracheostomy. Page last reviewed 26 January 2024. https://www.nhs.uk/conditions/tracheostomy/
20. NHS. Hernia. Page last reviewed 19 May 2026. https://www.nhs.uk/conditions/hernia/
21. NHS. Shortness of breath. Page last reviewed 30 January 2024. https://www.nhs.uk/symptoms/shortness-of-breath/
22. NHS. Iron deficiency anaemia. Page last reviewed 26 January 2024. https://www.nhs.uk/conditions/iron-deficiency-anaemia/
23. NHS. Low blood pressure (hypotension). Page last reviewed 11 July 2023. https://www.nhs.uk/conditions/low-blood-pressure-hypotension/
24. NHS. Heart failure. Page last reviewed 26 June 2026. https://www.nhs.uk/conditions/heart-failure/
25. NHS. Falls. Page last reviewed 6 March 2025. https://www.nhs.uk/conditions/falls/
26. NHS. Fainting. Page last reviewed 17 August 2026. https://www.nhs.uk/symptoms/fainting/
27. NHS. Head injury and concussion. Page last reviewed 29 May 2025. https://www.nhs.uk/conditions/head-injury-and-concussion/
28. NHS. Help for suicidal thoughts. Page last reviewed 26 April 2024. https://www.nhs.uk/mental-health/feelings-symptoms-behaviours/behaviours/help-for-suicidal-thoughts/
29. Sport and Recreation Alliance and UK Government. UK concussion guidelines for non-elite (grassroots) sport. Published 2023, updated November 2024. https://sportandrecreation.org.uk/campaigns-and-policy/concussion/concussion-guidelines-for-grassroots-sport-html-version

Written and checked by the PocketPhysio editorial team. Last updated 2026-11-03.

This page is general education, not a diagnosis or a personal treatment plan. See a physiotherapist or doctor for advice about your own situation.