Factors associated with functional recovery after intensive care unit discharge in patients with mechanical ventilation: A multi-centre prospective observational study

Abstract

Objective

The rehabilitation of patients with disabilities post-intensive care unit (ICU) discharge is gaining importance and we aimed to identify factors associated with recovery in this study.

Design

This study was a secondary analysis of a multi-centre cohort study.

Setting

Nine centres in Japan.

Participants

A total of 121 patients admitted to the ICU who used an invasive ventilator for >48 h were the participants of this study.

Main measures

The relative functional gain and rehabilitation efficiency index, based on the Barthel Index, were calculated from the time of ICU discharge to hospital discharge. Factors related to the relative functional gain and rehabilitation efficiency index were analysed using multiple regression analysis.

Results

The median relative functional gain value was 85% and the median rehabilitation efficiency index value was 1.61 points/day. Multiple regression analysis showed that relative functional gain was significantly associated with ventilator duration (β = −1.420, p < 0.001), the Medical Research Council score at ICU discharge (β = 1.557, p < 0.001), the Barthel Index at ICU discharge (β = 0.501, p < 0.001) and rehabilitation hours in general wards (β = 0.591, p = 0.008). The rehabilitation efficiency index was significantly associated with ventilator duration (β = −0.089, p = 0.022) and Medical Research Council score at ICU discharge (β = 0.098, p < 0.001).

Conclusions

Our findings highlight the importance of post-ICU rehabilitation, particularly in patients with prolonged ventilation or reduced muscle strength, and support the clinical utility of rehabilitation impact indices in monitoring recovery trajectories.

Keywords

Functional disabilities intensive care unit mechanical ventilation Barthel index relative functional gain rehabilitation efficiency index

Clinical Message

Functional recovery in critically ill patients often remains incomplete in the acute phase, which highlights the need for optimised post-intensive care unit (ICU) rehabilitation strategies.

Key factors influencing recovery included mechanical ventilation duration, muscle strength at ICU discharge, Barthel Index at ICU discharge, and rehabilitation time in the general ward.

Introduction

In recent years, the short-term mortality rate of critically ill patients has improved; however, functional impairment after discharge from the ICU has become increasingly important because long-term disability remains. The main goal of rehabilitation in critically ill patients is to improve their quality of life by improving their ability to perform activities of daily living (ADL).^1,2 However, it has been shown that post-intensive care syndrome reduces ADL abilities.³ Guidelines issued by the Japanese Society of Intensive Care Medicine recommend rehabilitation after discharge from the ICU.⁴ However, the optimal intensity, frequency, duration, and timing of rehabilitation after ICU discharge have not been clarified.^4,5 In addition, the effectiveness of intensified rehabilitation in certain ICU survivors, such as critically ill patients with post-intensive care syndrome, frailty, or sarcopenia, remains unclear.⁵

Given the heterogeneity of recovery among ICU survivors, objective and comprehensive measures are required to evaluate the effects of rehabilitation interventions. The effectiveness of rehabilitation is assessed by the performance of ADL, with rehabilitation impact indices used to measure outcomes.^6,7 Previous studies, such as the RECOVER trial, have reported mixed findings regarding the impact of rehabilitation intensity on functional outcomes in ICU survivors, thus highlighting the complexity of recovery trajectories.⁸ This inconsistency underscores the need for robust and standardised metrics, such as rehabilitation impact indices, to better capture and compare rehabilitation effects across patient populations. The rehabilitation impact indices incorporate factors such as pre-admission functional status, functional status at admission, functional status at discharge from the general ward, and duration of the rehabilitation programme to quantify functional recovery. This allows clinicians to better understand the rehabilitation trajectory and tailor rehabilitation plans accordingly.

Although rehabilitation impact indices have been applied in various conditions, such as stroke, orthopaedic surgeries, and pneumonia and in elderly inpatients, their use in assessing ICU recovery has not yet been explored.^6,7,9–12 This is important because evidence on the association between rehabilitation intensity and functional recovery in ICU survivors remains mixed, as observed in studies such as the RECOVER trial.⁸ The rehabilitation impact indices have also been applied in the acute and subacute phases in rehabilitation hospitals, with several studies reporting factors associated with rehabilitation outcomes.^9,12 However, no studies have investigated rehabilitation impact indices in ICU survivors, and data on the rate and extent of functional recovery in these patients would be useful for determining the frequency and duration of inpatient rehabilitation for those with critical illness.

This study aimed to identify factors associated with rehabilitation impact indices in ICU survivors.

Methods

Study Design and Patient Selection

This is a post-hoc analysis of the Investigation of Physical Activity of Mechanically (IPAM) Ventilated patients in the ICU (UMIN ID: 000047578).¹³ The IPAM study with data from hospitalisation between September 2022 and March 2023 is a multi-centre observational prospective cohort study. This study was approved by the Ethics Committee of our institution (Ethical Approval Number: 202204) and nine other participating hospitals. Informed consent was obtained from all patients, and all methods of this study were performed in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.¹⁴ Nine ICUs in hospitals participated in the study. Of the nine participating hospitals, six (67%) were tertiary emergency hospitals and three were secondary emergency hospitals. All ICUs were mixed medical and surgical ICUs.

Inclusion criteria were patients supported by mechanical ventilation in the ICU for more than 48 h. Exclusion criteria were age less than 18 years, inability to walk independently for at least 2 weeks prior to admission, central nervous system disorders, or inability to communicate due to pre-existing mental status, terminal illness, and coronavirus infection.

Early Mobilisation Protocol

In this study, we sought to mobilise all subjects equally and daily under a five-level protocol (level 1: Passive range of motion and respiratory physical therapy including postural drainage, thoracic squeeze technique, and suctioning manoeuvres; level 2: Active range of motion; level 3: Sitting exercise; level 4: Standing exercise; and level 5: Walking exercise) tailored for each participating hospital.¹⁵ After discharge from the ICU, a physical or occupational therapist provided each patient with at least 20 min of rehabilitation on weekdays, including muscle strengthening, balance, gait, and stair exercises, according to the rehabilitation policy of the general ward of each hospital. Protocols for ICU care were not standardised or shared but were based on recent standard guidelines, including the 2018 Pain, Agitation/sedation, Delirium, Immobility, and Sleep guidelines,¹⁶ nutrition guidelines,¹⁷ and guidelines for mechanical ventilation management.¹⁸ The physiotherapists were not exclusively assigned to the ICU but provided interventions as needed on the basis of doctors’ referrals.

Data Collection

The primary outcomes were relative functional gain and rehabilitation efficiency index.^6,7,9,12 ADLs were assessed using the Barthel Index¹⁹, with total Barthel Index scores ranging from 0 (totally dependent) to 100 (independent), with higher scores indicating greater independence. The Barthel Index at each time point was used to calculate the following:

Relative functional gain = [(Barthel Index at discharge−Barthel Index at ICU discharge)/(Barthel Index before admission−Barthel Index at ICU discharge)]*100

Rehabilitation efficiency index = (Barthel Index at discharge−Barthel Index at ICU discharge)/duration of hospitalisation after ICU discharge

The relative functional gain was expressed as a percentage reflecting the percentage of potential improvement actually achieved in the hospital, with a higher relative functional gain indicating a greater improvement in the ability to perform ADLs. The rehabilitation efficiency index indicates the mean value of incremental points per day.⁶

At the time of ICU admission, the following basic patient information was recorded: Age, sex, body mass index, Acute Physiology and Chronic Health Evaluation II score, Sequential Organ Failure Assessment score, Charlson Comorbidity Index, pre-admission Barthel Index, and the diagnosis at the time of ICU admission. Other variables and parameters included the duration of mechanical ventilation, mean daily rehabilitation time during ICU stay, Medical Research Council score at ICU discharge, Barthel Index at ICU discharge, length of stay in the general ward, mean daily rehabilitation time in the general ward, and Barthel Index at discharge.

Sample Size

A recent study¹² reported that the effect size (f²) of the multiple regression analysis for the relative functional gain of the motor Functional Independence Measure score was 0.470 (in this multiple regression analysis, 11 variables were independently and significantly associated with the relative functional gain motor Functional Independence Measure score). We expected to observe similar effect sizes in the multiple regression analysis for the relative functional gain and efficiency of the Barthel Index in this study. An a priori sample size calculation with an effect size (f²) of 0.470, power of 0.99, alpha error of 0.05, and number of predictors set as 5 indicated that a sample size of at least 63 participants was required. Sample size calculations were conducted using G*Power software version 3.1.9.2.

Statistical Analysis

Univariate regression analysis (unadjusted) and multiple regression analysis (forced entry method) were conducted to explore the factors influencing relative functional gain and rehabilitation efficiency index. Age, sex, and pre-admission Barthel Index,^6,7 were entered as variables to be adjusted. Independent variables were factors affecting outcomes in patients with critical illness based on previous studies and included Charlson Comorbidity Index,²⁰ Acute Physiology and Chronic Health Evaluation score,²¹ Sequential Organ Failure Assessment score,²¹ ventilator duration,^2,22 Medical Research Council score at ICU discharge,²³ Barthel Index at ICU discharge,^6,7 rehabilitation time per day at ICU admission,^15,24 and rehabilitation time per day in the general ward. The Variance inflation factor was used to assess multicollinearity. Multicollinearity was considered to exist if the Variance inflation factor value was greater than 3. All statistical analyses were performed using SPSS 23.0 software (IBM Corporation). Statistical significance was set at p-values <0.05.

Results

Baseline Characteristics

Overall, 671 patients were admitted to the ICU and 152 patients (23%) were enrolled after excluding 519 patients (77%) who met the exclusion criteria. Of the enrolled patients, 121 were included in this study after excluding 31 who died in the ICU (Figure 1).

The baseline characteristics of the study participants are presented in Table 1. The median age was 74 years (interquartile range (IQR) 64–80), and the median pre-admission Barthel Index was 100 points (IQR 100–100), with most patients being fully independent in ADL. The diagnosis at ICU admission was 24 (20%), cardiac disease in 50 (41%), gastrointestinal surgery in 25 (21%), and other causes in 22 (18%). The median daily rehabilitation time in the ICU was 21.4 min (IQR 15.6–33.5), while the median daily rehabilitation time in the general ward was 24.2 min (IQR 17.0–32.7). The ADL evaluation showed median Barthel Index scores of 15 (IQR 5–40) at ICU discharge and 90 (IQR 55–100) at general ward discharge, with a median post-ICU length of stay of 34 days (IQR 14–41).

Table 1.

Baseline characteristics of the 121 patients.

Baseline characteristics	All patients, n = 121
Age (years), median [IQR]	74[64–80]
Sex (male), n (%)	72 (60)
BMI (kg/m²), median [IQR]	21 [18–24]
CCI, median [IQR]	1 [1–3]
BI before hospitalisation, n (%)^a	100[100–100]
ICU admission diagnosis, n (%)
Acute respiratory failure	24 (20)
Cardiovascular disease	50 (41)
Gastric or colonic surgery	25 (21)
Other diagnoses	22 (18)
APACHE II score, median [IQR]	22 [16–26]
SOFA at ICU admission, median [IQR]	7 [4–10]
The use of continuous vasopressor during ICU stay, n (%)	80 (66)
The use of steroids during ICU stay, n (%)	10 (8)
The use of neuromuscular blocking agent during ICU stay, n (%)	12 (10)
Duration of mechanical ventilation, median [IQR]	5 [3–9]
ICU length of stay, median [IQR]	8 [6–12]
Medical Research Council score at ICU discharge, median [IQR]	48 [38–54]
Barthel Index at ICU discharge, median [IQR]	15 [5–40]
Barthel Index at hospital discharge, median [IQR]	90 [55–100]
Rehabilitation
No. of minutes of rehabilitation per day in ICU, median [IQR]	21.4 [15.6–35.0]
No. of minutes of rehabilitation per day in general ward, median [IQR]	24.2 [17.0–32.7]
Hospital length of stay, median [IQR]	37 [23–57]
Discharge to home, n (%)	71 (58)
Hospital mortality, n (%)	5 (4)
Relative functional gain, median [IQR]	85 [52–100]
Rehabilitation efficiency index, median [IQR]	1.61 [0.68–3.28]

Data are presented as median [interquartile range] or number (%).

IQR: interquartile range; BMI: body mass index; CCI: Charlson Comorbidity Index; BI: Barthel Index; ICU: intensive care unit; APACHE: Acute Physiology and Chronic Health Evaluation; SOFA: Sequential Organ Failure Assessment; ICU-AW: intensive care unit acquired weakness.

Relative Functional Gain

The median relative functional gain value was 85% (IQR 52–100). Univariate analysis showed significant differences in Acute Physiology and Chronic Health Evaluation II score, ventilator duration, Medical Research Council score ICU discharge, Barthel Index at ICU discharge, and rehabilitation time per day in the general ward. Multivariate analysis adjusted for age, sex, and pre-admission Barthel Index showed significant differences in ventilator duration (β=−1.420, p < 0.001), Medical Research Council score at ICU discharge (β=1.557, p < 0.001), Barthel Index at ICU discharge (β=0.501, p < 0.001), and rehabilitation time in the general ward (β=0.591, p = 0.008) (Table 2).

Table 2.

Relationships between relative functional gain and other variables (n = 121).

Variables	Unadjusted			Adjusted*
	Regression coefficient β		p value	Regression coefficient β		p value
	Estimate	95%CI	p value	Estimate	95%CI	p value
CCI	−3.120	−6.451, 0.210	0.066	−1.302	−4.543, 1.939	0.428
APACHE II score	−1.064	−1.959, −0.172	0.020	−0.826	−1.657, 0.004	0.051
SOFA	−0.654	−2.577, 1.269	0.502	−0.491	−2.254, 1.271	0.582
Duration of mechanical ventilation	−1.595	−2.344, −0.847	<0.001	−1.420	−2.121, 0.720	<0.001
Medical Research Council score at ICU discharge	1.730	1.316, 2.144	<0.001	1.557	1.166, 1.948	<0.001
Barthel Index at ICU discharge	0.576	0.276, 0.876	<0.001	0.501	−0.217, 0.785	<0.001
Time of rehabilitation per day in ICU	−0.013	−0.367, 0.342	0.944	−0.020	−0.348, 0.308	0.905
Time minutes of rehabilitation per day in general ward	0.683	0.214, 1.153	0.005	0.591	0.157, 1.025	0.008

*Adjusted for age, sex, pre-admission Barthel Index.

CI: confidence interval; CCI: Charlson Comorbidity Index; APACHE: Acute Physiology and Chronic Health Evaluation; SOFA: Sequential Organ Failure Assessment; ICU: intensive care unit.

Rehabilitation Efficiency Index

The median rehabilitation efficiency index value was 1.61 points/day (IQR 0.68–3.28). Univariate analysis showed significant differences in ventilator duration, Medical Research Council score at ICU discharge, and Barthel Index at ICU discharge. Multivariate analysis showed that ventilator duration (β=−0.089, p = 0.022) and Medical Research Council score at ICU discharge (β=0.098, p < 0.001) were significantly associated (Table 3).

Table 3.

Relationships between rehabilitation efficiency index and other variables (n = 121).

Variables	Unadjusted			Adjusted*
	Regression coefficient β		p value	Regression coefficient β		p value
	Estimate	95%CI	p value	Estimate	95%CI	p value
CCI	−0.202	−0.536, 0.131	0.232	−0.092	−0.431, 0.246	0.591
APACHE II score	−0.038	−0.130, 0.054	0.411	−0.024	−0.113, 0.066	0.602
SOFA	−0.127	−3.201, 0.065	0.192	−0.116	−0.302, 0.070	0.218
Duration of mechanical ventilation	−0.101	−0.179, −0.024	0.011	−0.089	−0.166, −0.013	0.022
Medical Research Council score at ICU discharge	0.110	0.063, 0.158	<0.001	0.098	0.050, 0.145	<0.001
Barthel Index at ICU discharge	0.031	0.001, 0.062	0.047	0.023	−0.008, 0.054	0.147
Time of rehabilitation per day in ICU	−0.006	−0.041, 0.029	0.733	−0.007	−0.041, 0.027	0.684
Time minutes of rehabilitation per day in general ward	0.031	−0.017, 0.079	0.206	0.025	−0.021, 0.071	0.288

*Adjusted for age, sex, pre-admission Barthel Index.

CI, confidence interval; CCI, Charlson Comorbidity Index; APACHE, Acute Physiology and Chronic Health Evaluation; SOFA, Sequential Organ Failure Assessment; ICU, intensive care unit.

VIF for all independent variables was less than 3.

Discussion

In this study, we examined relative functional gain, rehabilitation efficiency index, and their associated factors in patients with critical illness admitted to the ICU. The relative functional gain after ICU discharge was 85%, and was significantly related to ventilator duration, Medical Research Council score at ICU discharge, BI at ICU discharge, and rehabilitation time in the general ward. The rehabilitation efficiency index was 1.61 points/day and was significantly associated with ventilator duration and Medical Research Council score at ICU discharge. To the best of our knowledge, this is the first report investigating relative functional gain and rehabilitation efficiency index after ICU discharge.

Rehabilitation impact indices such as relative functional gain and rehabilitation efficiency index are used to determine the effectiveness of rehabilitation. After ICU discharge, relative functional gain was 85% and rehabilitation efficiency index was 1.61 points/day. In comparison, previous studies have reported a relative functional gain of 31% and a rehabilitation efficiency index of 0.47 points/day in subacute stroke patients,²⁵ 33% and 0.8 points/day in patients with neck fractures,²⁶ and 61.7% and 2 points/day in hospitalised elderly patients.⁷ Although relative functional gain and rehabilitation efficiency index are affected by the length of hospital stay^7,25 and cannot be simply compared, the results suggest that functional recovery in patients with critical illness after ICU discharge is higher than that in patients with stroke or hip fracture. However, ICU survivors experience generalised wasting even in the absence of obvious functional impairment, such as paralysis or fractures, and their ADL is limited by post-intensive care syndrome, which presents with physical, cognitive, and mental impairment after ICU discharge.^3,4 Furthermore, critically ill patients may continue to experience health decline even five years post-discharge, highlighting the issue of long-term disability.^27,28 Further research is warranted to clarify the association between rehabilitation impact indices and long-term functional outcomes.

In this study, key factors associated with functional recovery included ventilator duration, Medical Research Council score, Barthel Index score at ICU discharge, and rehabilitation time in the general ward. Prolonged ventilator use has been associated with activity limitations at six months² and delayed mobilisation,²² indicating its relevance to post-ICU recovery. Muscle weakness at ICU discharge is also known to impair functional capacity,²³ and more than one-third of acute respiratory distress syndrome survivors experience persistent weakness that limits ADL and mobility.³ These findings support the notion that muscle strength at ICU discharge is a critical determinant of functional recovery in critically ill patients.

An interesting finding of this study was that relative functional gain after ICU discharge was associated with rehabilitation time in the general ward, but not in the ICU. The RECOVER trial, which implemented in-hospital rehabilitation interventions, showed no significant effect post-ICU.⁸ However, the average hospital stay was short (11 days), and the outcome was mobility at three months, suggesting the assessment may have lacked sensitivity to the intervention.²⁹ In contrast, our study used changes in Barthel Index, which reflects overall ADL and is a reliable and responsive measure at ICU discharge,³⁰ making it suitable for evaluating post-intensive care syndrome.³¹ Additionally, the median post-ICU hospital stay in our cohort was 28 days – longer than in prior studies – potentially allowing for more rehabilitation and greater Barthel Index improvement. While recent systematic reviews report that ICU rehabilitation improves survival and non-hospital days up to 180 days,³² we found no association between ICU rehabilitation time and ADL recovery. This may be due to ongoing debate regarding how to define early rehabilitation intensity in the ICU.³³ In our study, rehabilitation time was used as a proxy for intensity, though time alone may not fully reflect it. A combined metric incorporating both time and mobilisation-level has recently gained attention.¹³ Future studies should explore its relevance to functional recovery after ICU discharge. Moreover, the factors associated with relative functional gain and rehabilitation efficiency index differed, possibly owing to their inherent characteristics and trade-offs with hospital length of stay.^25,34 Further research is required to determine the optimal duration of rehabilitation for patients who are critically ill.

This study was conducted in nine ICUs, including both large ICUs in urban areas and smaller ICUs, thus ensuring the external validity of the results. However, there are several limitations to this study. First, the measure of rehabilitation following ICU discharge was limited to the time of rehabilitation sessions. Rehabilitation involves adjusting intensity, frequency, time, and type to set an appropriate load. The definition of rehabilitation intensity after ICU discharge has not been clearly established so far.^4,5 Since rehabilitation time was found to be associated with recovery in ADL after ICU discharge in this study, therefore time was suggested to be an important factor in defining rehabilitation intensity. Second, the results were limited to short-term follow-up. This study focused on changes during hospitalisation and did not track long-term effects post-discharge. Although it has been reported that functional decline at the time of hospital admission is associated with long-term prognosis,³⁵ it remains unclear whether the degree and speed of functional recovery during the hospitalisation period among ICU survivors is related to long-term disability. To further verify these findings and examine causal relationships, a multi-centre randomised controlled trial involving a larger patient population is warranted.

Footnotes

Acknowledgments

The authors would like to thank the study coordinators PT Kaito Kochi, PT Keisuke Mizutani, Ns Mika Ohno, Ns Yayoi Honjo, Dr Yasunari Morita, PT Yoshie Hirota, PT Takafumi Nishizaki, PT Kenichi Maeda, PT Takuro Toyoda, PT Yuki Matsumoto, PT Yuji Naito, PT Daisuke Morimoto, PT Yuji Mori, PT Naoki Takeshita, PT Fumiaki Senzaki, PT Kazuki Ogawa, PT Joichi Yamasaki, PT Naoya Sato, PT Hiroyoshi Yano, PT Shunsuke Ishii, PT Shin Yoshimoto, PT Hiroyuki Kozu, PT Ryota Ogata, PT Ryo Watanabe, PT Ryota Ogata, PT Tomohiro Yoshikawa, PT Ryosuke Sakaguchi, PT Daigo Kato, PT Yasuki Koyanagi, PT Sho Suzuki, PT Chisaki Kumazawa, PT Yuuta Sato, PT Kota Yamauchi, PT Kei Goto, PT Shota Tanaka, OT Tokuaki Shinya, PT Daisetsu Yasumura, PT Yuuichi Miyagi, PT Takuya Tonaki, PT Shinya Kawabata, PT Hiroyuki Touyama, PT Taisuke Kamiya, PT Mituru Kume.

Author Contributions

Kota Yamauchi: Investigation and writing – original draft. Shinichi Watanabe: Project administration and conceptualisation. Yuji Naito and Yoshie Hirota: conceptualisation and investigation. Kei Goto, Shota Tanaka, Tokuaki Shinya, Kazuki Ogawa, Tomohiro Yoshikawa: Investigation. Yoshihisa Fujino: Formal Analysis.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval

This study is a post-hoc analysis of the IPAM study (Investigation of Physical Activity of Mechanically Ventilated Patients in the ICU, UMIN ID; 000047578. This IPAM study was approved by the Ethics Committee of Gifu University of Medical Science (202204) and nine other participating hospitals. The study was conducted in accordance with the Declaration of Helsinki.

Informed Consent

All participants were fully informed of the study and provided written informed consent for participation in the study.

Data Availability

Anonymised individual participant data that underlie the results reported in this article (text, tables, figures) are available upon reasonable request from the corresponding author.

ORCID iD

Kota Yamauchi

Registration

The trial was registered with the UMIN Clinical Trials Registry (registration number: UMIN000047578). Registration began on September 1, 2022, and closed on March 31, 2023.

References

World Health Organization. International classification of functioning, disability and health (ICF). 2001. http://www.who.int/classifications/icf/en/ (accessed 24 August 2024).

Hodgson

Udy

Bailey

, et al. The impact of disability in survivors of critical illness. Intensive Care Med 2017; 43: 992–1001.

Fan

Dowdy

Colantuoni

, et al. Physical complications in acute lung injury survivors: a two-year longitudinal prospective study. Crit Care Med 2014; 42: 849–859.

Unoki

Hayashida

Kawai

, et al. Japanese Clinical practice guidelines for rehabilitation in critically ill patients 2023 (J-ReCIP 2023). J Intensive Care 2023; 11: 47.

Taito

Yamauchi

Tsujimoto

, et al. Does enhanced physical rehabilitation following intensive care unit discharge improve outcomes in patients who received mechanical ventilation? A systematic review and meta-analysis. BMJ Open 2019; 9: e026075.

Koh

Chen

Petrella

, et al. Rehabilitation impact indices and their independent predictors: A systematic review. BMJ Open 2013; 3: e003483.

Sánchez-Rodríguez

Miralles

Muniesa

, et al. Three measures of physical rehabilitation effectiveness in elderly patients: A prospective, longitudinal, comparative analysis. BMC Geriatr 2015; 15: 142.

Walsh

Salisbury

Merriweather

, et al. Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: The RECOVER randomized clinical trial. JAMA Intern Med 2015; 175: 901–910.

Yamaoka

Chono

Fukumoto

, et al. Impact of number of drugs on rehabilitation outcomes in patients after traumatic brain injury: A retrospective cohort study. PM R 2021; 13: 496–502.

10.

Hasebe

Momosaki

Sawabe

, et al. Effectiveness of weekend physical rehabilitation for functional recovery in geriatric patients with hip fracture. Geriatr Gerontol Int 2018; 18: 1143–1146.

11.

Akazawa

Kishi

Hino

, et al. Intramuscular adipose tissue in the quadriceps is more strongly related to recovery of activities of daily living than muscle mass in older inpatients. J Cachexia Sarcopenia Muscle 2021; 12: 891–899.

12.

Woo

Aoki

Kataoka

, et al. Early walking time is associated with recovery of activities of daily living during hospitalization in older patients with community-acquired pneumonia: A single-center prospective study. Geriatr Gerontol Int 2021; 21: 1099–1104.

13.

Watanabe

Liu

Hirota

, et al. Investigating dose level and duration of rehabilitation of mechanically ventilated patients in the ICU (IPAM): A multicenter prospective observational cohort study in Japan. Respir Care 2025; 70: 278–286.

14.

Vandenbroucke

von Elm

Altman

, et al. Strengthening the reporting of observational studies in epidemiology (STROBE): explanation and elaboration. Int J Surg 2014; 12: 1500–1524.

15.

Watanabe

Liu

Kozu

, et al. Association between mobilization level and activity of daily living independence in critically ill patients. Ann Rehabil Med 2023; 47: 519–527.

16.

Devlin

Skrobik

Gélinas

, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med 2018; 46: e825–e873.

17.

Singer

Blaser

Berger

, et al. ESPEN Guideline on clinical nutrition in the intensive care unit. Clin Nutr 2019; 38: 48–79.

18.

Tasaka

Ohshimo

Takeuchi

, et al. ARDS Clinical practice guideline 2021. Respir Investig 2022; 60: 446–495.

19.

Katz

P P

. Measures of adult general functional status: The Barthel Index, Katz Index of Activities of Daily Living, Health Assessment Questionnaire (HAQ), MACTAR Patient Preference Disability Questionnaire, and Modified Health Assessment Questionnaire (MHAQ). Arthritis Care Res 2003; 49: 15–27.

20.

Shang

, et al. Clinical characteristics and risk factors associated with ICU-acquired infections in sepsis: A retrospective cohort study. Front Cell Infect Microbiol 2022; 12: 962470.

21.

Tran

Nagaria

Patel

, et al. Severity-of-Illness scores and discharge disposition in patients admitted to long-term acute care hospitals. Am J Crit Care 2023; 32: 375–380.

22.

Watanabe

Liu

Nakamura

, et al. Association between early mobilization in the ICU and psychiatric symptoms after surviving a critical illness: A multi-center prospective cohort study. J Clin Med 2022; 11: 2587.

23.

Sidiras

Patsaki

Karatzanos

, et al. Long term follow-up of quality of life and functional ability in patients with ICU acquired weakness – a post hoc analysis. J Crit Care 2019; 53: 223–230.

24.

Hodgson

Bailey

Bellomo

, et al. A binational multicenter pilot feasibility randomized controlled trial of early goal-directed mobilization in the ICU. Crit Care Med 2016; 44: 1145–1152.

25.

Koh

Chen

Cheong

, et al. Trade-offs between effectiveness and efficiency in stroke rehabilitation. Int J Stroke 2012; 7: 606–614.

26.

Shiri-Sharvit

Arad

Mizrahi

, et al. The association between psychotropic medication use and functional outcome of elderly hip-fracture patients undergoing rehabilitation. Arch Phys Med Rehabil 2005; 86: 1389–1393.

27.

Herridge

Tansey

Matté

, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011; 364: 1293–1304.

28.

Carey

Prescott

Iwashyna

, et al. Changes in self-rated health after sepsis in older adults: A retrospective cohort study. Chest 2020; 158: 1958–1966.

29.

Cox

Hough

. Improving functional recovery after critical illness. JAMA Intern Med 2015; 175: 911–912.

30.

Dos Reis

Figueiredo

Biscaro

RRM

, et al. Psychometric properties of the Barthel Index used at intensive care unit discharge. Am J Crit Care 2022; 31: 65–72.

31.

Nakanishi

Liu

Kawauchi

, et al. Instruments to assess post-intensive care syndrome assessment: A scoping review and modified Delphi method study. Crit Care 2023; 27: 430.

32.

Paton

Chan

Tipping

, et al. The effect of mobilization at 6 months after critical illness - meta-analysis. NEJM Evid 2023; 2: EVIDoa2200234.

33.

Hodgson

Kho

da Silva

. To mobilise or not to mobilise: is that the right question? Intensive Care Med 2023; 49: 1000–1004.

34.

Damiani

Mangone

Paoloni

, et al. Trade-Offs with rehabilitation effectiveness (REs) and efficiency (REy) in a sample of Italian disabled persons in a in post-acuity rehabilitation unit. Ann Ig 2020; 32: 327–335.

35.

Loyd

Markland

Zhang

, et al. Prevalence of hospital-associated disability in older adults: A meta-analysis. J Am Med Dir Assoc 2020; 21: 455–461. .e5.