# ICU Physiotherapy > ICU Physiotherapy: early mobilisation and the ABCDEF bundle, ventilator and secretion care, MRC sum score for ICU-acquired weakness, safety screens. - Canonical URL: https://prepelephant.com/topics/allied/physiotherapy/icu-physiotherapy - Exam / course: Allied Health · Subject: Physiotherapy - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "ICU Physiotherapy", PrepElephant, https://prepelephant.com/topics/allied/physiotherapy/icu-physiotherapy ## Direct answer The ventilated patient in bed four is already losing muscle — critical illness strips roughly 2 per cent of muscle mass per day in the first week of intensive care, and the physiotherapist's job is to interrupt that loss. ICU physiotherapy spans three streams: respiratory care (positioning including prone ventilation in ARDS, secretion clearance, suctioning, weaning support), early mobilisation (passive movements progressing through active-assisted, bed-edge sitting, standing, walking), and prevention of immobility's complications — contractures, pressure injuries, ICU-acquired weakness. Progression is guided by the ABCDEF liberation bundle (assess and manage pain, both spontaneous awakening and breathing trials, choice of sedation, delirium monitoring, early mobility, family engagement), with safety screens checked before every session and weakness quantified by the Medical Research Council sum score, below 48 out of 60 defining ICU-acquired weakness. ## What you must remember - **ICU-acquired weakness:** diagnosed by the MRC sum score — six muscle pairs, each graded 0-5 — a score below 48 out of 60 in an awake, cooperative patient defines it; it blends critical illness polyneuropathy and myopathy and predicts prolonged weaning. - **ABCDEF bundle:** pain assessment, spontaneous awakening and breathing trials, sedation choice, delirium monitoring, early exercise and mobility, family engagement — the framework that makes physiotherapy possible by keeping patients awake enough to move. - **Early mobilisation ladder:** passive range of motion and positioning → active-assisted exercise → sitting over the bed edge → standing/pivot transfer → marching → ambulation, advanced only when cardiovascular and respiratory safety screens hold. - **Safety screens to halt a session:** mean arterial pressure roughly below 60-65 mmHg or falling, heart rate above about 120-140 per minute, respiratory rate above roughly 30-35, saturation below about 88-90%, rising vasopressor doses, uncontrolled arrhythmia, unresolved pneumothorax or unstable fracture — and pause sedation-heavy assessments. - **Ventilator-associated pneumonia prevention:** head-of-bed elevation 30-45°, oral care, subglottic suctioning and tube management bundled together — physiotherapy shares this responsibility. - **Prone positioning in ARDS:** applied for at least 16 consecutive hours per cycle in selected moderate-to-severe patients, with the physiotherapist managing pressure areas, airway security and postural drainage during the turn. - **Secretion clearance toolbox:** manual techniques, ventilator hyperinflation, endotracheal suctioning (pre-oxygenated, limited passes), cough assistance and, post-extubation, directed huffing and positive expiratory pressure. - **Diaphragm and weaning:** prolonged mechanical ventilation causes diaphragm weakness; inspiratory muscle training and spontaneous-breathing trials support weaning trials led by the intensivist. ## A day in the unit — one patient, one ladder Picture a 46-year-old with severe pneumonia, day 5 on the ventilator, sedation being lightened each morning for a spontaneous awakening trial. The physiotherapist starts the shift with the safety screen — ventilation settings, vasopressor dose, lines, rhythm — then turns her prone for 16 hours with the team, padding pressure points and securing the tube. When she awakens and follows commands, passive ankle pumps and shoulder movements become active-assisted, then the bed is cranked upright; by day 8 she sits on the edge with the ventilator on a support setting, and day 10 brings a pivot to the chair with inline suction at the ready. Once extubated, the focus flips: MRC grading (44 — weakness confirmed), seated endurance, huffing with a PEP device, and a plan that follows her to the ward, because muscle lost in five ventilated days takes weeks to regain. Every rung is documented — an unrecorded progression is a repetition of risk. ## What exams probe — and what Indian units actually do Indian BPT and MPT papers frame ICU physiotherapy as define-and-list — intensive physiotherapy aims, indications and contraindications for chest physiotherapy, the MRC scale, positioning in ARDS — followed by a long answer designing a mobilisation protocol for a ventilated patient, where the ladder plus safety parameters carry the marks. The viva favourite is contraindications: haemodynamic instability, unresolved pneumothorax, raised intracranial pressure, active haemoptysis, unstable fractures and untreated coagulopathy all belong in the list. Practically, units in Indian government hospitals often run one therapist across a dozen beds, so examiners respect answers that prioritise — head elevation and suctioning for all, early mobility reserved for screened patients — over a wish list no staffing could deliver. That triage honesty, backed by the ABCDEF structure, is what separates a clinical answer from a textbook copy. ## Frequently asked questions ### How is ICU-acquired weakness diagnosed at the bedside? By the MRC sum score grading six bilateral muscle groups from 0 to 5; a total below 48 out of 60 in an alert, cooperative patient defines ICU-acquired weakness. ### What does the ABCDEF bundle stand for? Assess and manage pain, both spontaneous awakening and breathing trials, choice of light sedation, delirium monitoring, early exercise and mobility, and family engagement. ### Why is the head of the bed elevated 30-45 degrees? Head elevation reduces gastro-oesophageal reflux and microaspiration, lowering ventilator-associated pneumonia risk, provided spinal and haemodynamic stability allow it. ### How long should prone positioning be maintained in ARDS? Commonly at least 16 consecutive hours per session in selected moderate-to-severe ARDS patients, repeated daily while indicated, with pressure-area and airway care during each turn. ### When should a mobilisation session be stopped? For falling mean arterial pressure or rising vasopressors, heart rate above roughly 120-140, respiratory rate above about 35, desaturation below 88-90%, new arrhythmia, or patient distress — stop, reassess, and step down one rung of the ladder.