Physiotherapy 96 (2010) 228–233

An investigation of the use of passive movements in intensive

care by UK physiotherapists
R.C. Stockley ∗ , J. Hughes, J. Morrison, J. Rooney
Physiotherapy Programmes, Faculty of Health, Psychology and Social Care, Elizabeth Gaskell Campus,
Manchester Metropolitan University, Manchester M13 OJA, UK

Abstract
Objectives To investigate the current use of passive movements (PMs) by National Health Service (NHS) physiotherapists working with
sedated and ventilated patients in critical care settings.
Design Postal questionnaire.
Setting All open NHS critical/intensive care units in England, Northern Ireland, Scotland and Wales.
Participants Physiotherapists working in UK NHS critical/intensive care units.
Results Questionnaires were posted to 246 physiotherapists working in intensive care units; 165 (67%) were returned. One hundred and
fifty-two respondents routinely treated ventilated and sedated patients, of which 151 (99%) reported utilising PMs. They were used most
commonly (>70%) in patients admitted to critical care with medical, neurological or surgical problems. Respondents reported using a median
of five repetitions of PMs once daily, and the majority of respondents took joints to the end of range (>78%). Joints most commonly treated
included the shoulder, hip, knee, elbow and ankle. Heart rate and blood pressure were monitored by over 84% of respondents during treatment.
Conclusions Whilst there is little empirical evidence to underpin the use of PMs, this study found that PMs were used regularly by 99% of
respondents working in NHS critical care settings. Further work is now needed to evaluate the immediate and long-term effects of PMs in
critically ill patients to inform and develop future practice.
© 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Keywords: Critical care; Intensive care; Passive movements; Exercise

Introduction tolerance in conscious but critically ill patients [8,9]. In a

It is well recognised that critically ill patients decondition
quickly [1]. Bed rest, necessitated by ventilation and seda-
tion, produces rapid deteriorations in muscle strength and
cardiovascular conditioning [2,3]. These factors may be com-
pounded by catabolism, hypovolaemia, inflammation, sepsis
and poor nutritional status, resulting in muscle weakness and
reduced exercise tolerance [3–5]. These changes could con-
tribute to poorer health-related quality of life among people
who have been critically ill, many months after discharge
[6,7].
Physiotherapists working in critical care are frequently
involved in designing and carrying out participatory rehabil-
itative programmes to increase mobility, strength and exercise
∗ Corresponding author. Tel.: +44 0161 247 2971; fax: +44 0161 247 6571.
E-mail address: r.stockley@mmu.ac.uk (R.C. Stockley).
recent study, 94% of 111 physiotherapists surveyed in Aus-
tralia reported prescribing exercise routinely in critically ill
patients [10]. Early mobilisation and rehabilitation are rec-
ommended to ameliorate deterioration, restore condition and
reduce the duration of intensive care unit (ICU) and inpatient
stay [1,11,12]. Whilst a patient’s active participation in early
rehabilitation is optimal, this may not be possible for patients
who are sedated or unconscious. Consequently, early reha-
bilitation may comprise passive movements (PMs) for those
patients who are unable to participate actively [1,8].
PMs are described as movements performed without voli-
tional control [13]. They are accomplished by the therapist
moving a patient’s limbs, and are reported to be used com-
monly by physiotherapists in critically ill patients [8]. In the
UK, 28 out of 29 (97%) surveyed physiotherapists used PMs
routinely in critically ill patients [8]. Similar findings have
been reported from the USA [12], but neither of the studies

0031-9406/$ – see front matter © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.physio.2009.11.014
 R.C. Stockley et al. / Physiotherapy 96 (2010) 228–233
reported the parameters and methods of monitoring used by
therapists when applying PMs, nor did they specify the type
of patients in which PMs were used. Whilst PMs are recom-
mended by the European Respiratory Society and the Society
for Intensive Care Medicine [1], their effects have not been
established in critically ill patients [1,14], and investigation
of their effects has been identified as a research priority [15].
The possible effects of PMs may include increases in
metabolic and haemodynamic demands, such as increased
venous return and stroke volume [16,17], and could influ-
ence the inflammatory process. Passive leg exercise has been
shown to increase minute ventilation in a small study of
healthy participants [18], and may increase oxygen consump-
tion [14]. In a small study of 10 critically ill patients, it
was observed that inflammation was reduced after moderate
activity, although it is not clear if PMs would provide ade-
quate stimulus to elicit this effect [19]. PMs have also been
suggested to increase collagen re-organisation after injury,
maintain joint range and decrease contracture, although these
effects may require many hours of continuous treatment [20].
Whilst it is perceived that PMs are used widely by physio-
therapists, their use and the treatment parameters (frequency,
duration, method of application) in critically ill patients have
not been reported [8,10]. Therefore, this study sought to deter-
mine the current clinical use of PMs by UK physiotherapists
in fully ventilated and sedated critically ill patients.
Materials and methods
The number of National Health Service (NHS) trusts with
open level 3 ICU beds was provided by the Departments of
Health in England, Scotland, Wales and Northern Ireland.
The postal addresses of units within each trust were ascer-
tained by searching trust websites and by contacting hospitals
directly by telephone.
A questionnaire which comprised 12 items was developed
by the authors. A combination of open, closed and matrix
questions was utilised. Respondents were asked to base their
answers on their usual practice in fully ventilated (defined as
those requiring mandatory forms of ventilation) and sedated
patients. Five items detailed the experience of the physiother-
apist and the number of ICU beds at each facility, four items
investigated the use of PMs in different patient groups in
the ICU (e.g. neurological, orthopaedic), and the remainder
questioned the aims and methods of monitoring their effect.
Standardised definitions of PMs (movement of a joint through
range without effort or assistance from the patient) and end
of range (movement up to the point of resistance of a joint)
were provided.
The questionnaire was prepiloted by two senior physio-
therapists who worked in critical care in local trusts. After
minor revisions, the revised questionnaire (version 2) was
piloted by physiotherapists working in 20 randomly selected
ICUs in the UK. Minor adaptations were made from feed-
back from the pilot stage, and questionnaires (version 3)
229
were posted to every NHS ICU/critical care unit in the UK
(including the pilot sites) with an accompanying letter and
information sheet. These were addressed to the senior phys-
iotherapist working in intensive/critical care to promote a
greater return rate rather than addressing them to a senior
physician [8,9]. A coded, prepaid reply envelope was also
included to increase the return rate and to identify non-
returners [21]. Reminder letters were sent to those who had
not returned their questionnaires within 6 to 8 weeks.
Ethical approval was obtained from Manchester Metro-
politan University Research Ethics Committee. Participants
did not complete a consent form; consent was presumed when
participants returned completed questionnaires.
Data analysis
All data were coded to preserve anonymity and entered
into Statistical Package for the Social Sciences Version 16
(SPSS Inc., Chicago, IL, USA) by the authors. Descriptive
methods were used to summarise and present the data.
Results
Two hundred and forty-six ICUs were identified as open
at the start of the survey period. One hundred and fourteen
(46.5%) questionnaires were returned initially, and 51 addi-
tional questionnaires were returned after reminders were sent,
giving an overall response rate of 67% (165/246).
Thirteen questionnaires were returned uncompleted as
the hospital did not have open facilities for ventilated and
sedated patients. The remaining respondents (152/246, 62%)
reported working in ICUs with a median of nine critical care
beds (range 3 to 30). The median year of qualification as
a physiotherapist was 1998 (range 1966 to 2006), and the
respondents had a median of 10 years (range 2 to 42) of
postqualification clinical experience. One hundred and forty-
seven respondents provided their job title: 92 were senior
I/band 7 (11 and 81, respectively), 23 were senior II/band 6
(two and 21, respectively), seven were clinical specialists,
four were clinical leads/team leaders, two were at super-
intendent IV level, and one was a superintendent III. They
reported working with critically ill patients for a median of
6 years (range 0.75 to 42). Ninety-nine percent (151/152)
of respondents reported using PMs routinely in critically ill
patients.
Patient groups treated
Participants were asked to estimate the proportion of
patients they would usually treat over 1 month, and to identify
if they had been admitted to critical care primarily because
of neurological, orthopaedic, cardiology, surgical, medical
or other conditions. As shown in Table 1, physiotherapists
estimated that they treated surgical, neurological and medi-
230 R.C. Stockley et al. / Physiotherapy 96 (2010) 228–233

Table 1
The use of passive movements (PMs) in different patient groups.
Primary cause of admission to intensive care unit
Neurology Orthopaedic Cardiology Surgery Medicine Other
Mean % of patients seen in 1 month (range) 5 (0 to 100) 10 (0 to 100) 5 (0 to 50) 40 (0 to 80) 30 (0 to 80) 5 (0 to 80)
Mean % of patients receiving PMs routinely 72 69 52 70 75 61
Type of PMs (%)
Not used 25 27 40 24 18 10
Single 28 37 24 31 35 40
Patterns 22 15 17 21 24 20
Single and patterns 23 17 16 23 23 30
Taken to end of range (%) 78 82 91 87 89 90
Other reasons given for admission to intensive care unit were: cardiothoracic (n = 8), renal (n = 6), head and neck surgery (n = 5), burns and plastics (n = 5),
obstetric and gynaecological (n = 5) and haematological (n = 4).

Table 2
Joints to which passive movements (PMs) were performed routinely.
Upper limb No. of respondents using PMs in these joints Lower limb No. of respondents using PMs in these joints
Shoulder 130 Hip 127
Elbow 123 Ankle 127
Wrist 117 Knee 123
Hand 109 Feet 20
Neck 44 Toes 17
Others: Thumb 32 Forefoot 3
Subtalar 2
Shoulder girdle 7 Tarsal metatarsal 6
Jaw 1 Others: Lumbar spine 8
Patella 2
Pelvis 2
Sacroiliac joint 1
Other areas stated by respondents included specific areas in the upper quadrant and trunk (metacarpal phalangeal joints, n = 14; scapula, n = 5; thoracic spine,
n = 2) and lower limb (tendoachilles, n = 8; metatarsal phalangeal joints, n = 1).

cal patients most commonly. PMs were reported to be used
in all patient groups by the majority of respondents, utilis-
ing a combination of single joint movements and patterns of
movements (Table 1).
One hundred and twenty out of 152 (78%) respondents
reported that they performed PMs on a daily basis, seven
performed them every second day, and four performed them
every third day.
Frequency and repetitions
were most commonly reported in the lower limb. In the upper
limb, the use of PMs on the shoulder was reported by most
respondents, followed by the elbow and wrist.
Seventy-eight percent (118/152) of respondents stated that
they monitored the effects of PMs routinely. The monitors
reported during treatment are shown in Fig. 1.
The most frequently reported monitors were heart rate
(100/118; 85%) and blood pressure (99/118; 84%), and
the least reported monitor was pulmonary artery pressure
(15/118; 13%).

When PMs were performed, they were reported to be

undertaken once a day (range 1 to 2) in every group. There
was no difference between the number of repetitions esti-
mated to be used in different patient groups; a median of five
repetitions (range 0 to 20) was reported in all groups except
‘others’ in which participants reported using a median of two
repetitions (range 0 to 10).

Joints treated

Respondents were asked to list the joints in which they

performed PMs routinely. In the lower limb and upper limb,
respondents identified 20 and 21 areas where PMs were used,
respectively. As shown in Table 2, the hip, ankle and knee Fig. 1. Parameters monitored during passive movements (PMs).
 R.C. Stockley et al. / Physiotherapy 96 (2010) 228–233
Discussion
This study investigated the current use of PMs by NHS
physiotherapists in critically ill patients who were ventilated
and sedated.
At the time of writing, there were 2030 open level 3 NHS
ICU beds in the UK [22]. Many patients on these units are
assessed and treated by a physiotherapist. The results from
this study demonstrate that 99% (151/152) of physiothera-
pists working in this setting who returned this questionnaire
utilise PMs routinely in ventilated and sedated critically ill
patients. This is the first study to ascertain the use of PMs
in this patient group in the UK, and provides a valuable
indication of reported current clinical practice.
The results of this study are likely to be affected by the
limitations inherent to postal surveys. It is not possible to
rule out response bias, and it is possible that physiothera-
pists not using PMs did not return the questionnaire. If it is
assumed that all non-returners did not reply for this reason,
the findings still demonstrate that 61% of NHS physiother-
apists utilise PMs routinely in their treatment of critically
ill patients. Whilst others have reported higher return rates
in smaller samples (29/36, 81%; 126/167, 75%) [8,10], and
physiotherapists working in private settings were not sur-
veyed, the return rate in this study (67%) suggests that the
results are likely to be indicative of UK physiotherapeutic
practice.
A further limitation was that it was not possible to guar-
antee who responded to the questionnaire or the accuracy of
their answers. As questionnaires were addressed to the senior
physiotherapist, it was anticipated that the respondents would
be the most senior physiotherapist working in each unit. How-
ever, 19 respondents stated that they had worked in this setting
for less than 3 years. This suggests that, whilst senior phys-
iotherapists, they may not be the most senior physiotherapist
on the critical care unit, although it is unclear if this would
affect results. It was also assumed that respondents adhered
to the instructions provided. However, it is possible that they
may have partially or wholly based their answers upon their
practice in awake and/or unventilated patients on the critical
care unit. This would be likely to reduce the frequency of use
of PMs, as active assisted activities are likely to be utilised in
preference to PMs in conscious patients [8], and may mean
that the results underestimate the use of PMs in some patient
groups. Similarly, it is also recognised that several questions
asked respondents to describe their usual, routine practice
which cannot be assumed to mirror their actual practice.
Respondents were asked to select the main reason for
admission to the ICU from a list or to state the reason for
admission if it did not conform to these categories. They
reported that patients were most commonly admitted to the
ICU for medical and surgical reasons. Other reasons for
admission stated included burns and oncology. These find-
ings indicate that respondents worked with a wide range of
patient groups, increasing the external validity of the results
of this study.
231
PMs were reported to be used most often in medical,
surgical and neurological patients who were ventilated and
sedated, and used least often in patients admitted to the
ICU because of cardiac problems. The differences between
these groups could be attributed to several factors. Whilst
PMs can be used in people with neurological impairments
to begin re-education of the nervous system, cardiovascu-
lar instability may limit interaction with cardiac patients and
deter from early mobilisation, including PMs [23]. Indeed,
the effects of PMs on the cardiovascular system are reported
to include augmented venous return via the passive muscle
pump, increasing ventricular preload [16,17], which may not
be desirable for patients with cardiac insufficiency. It is also
postulated that a neurological feed forward mechanism may
increase heart rate on commencement of PMs [17], and feed-
back from joint receptors may increase cardiac output [24].
These factors may be sufficient to deter physiotherapists from
performing PMs routinely in cardiac patients, although it is
not clear if PMs performed therapeutically would provide
sufficient stimuli for these changes to occur [17,24]. It is also
possible that the relatively short ICU stay of some cardiac
patients for monitoring and weaning from ventilation imme-
diately after surgery, before being transferred to other wards,
may mean that PMs are not appropriate.
Reports of the type of PMs used (single joint, patterns of
movement or a combination of the two) appeared broadly
similar for each patient group. Whilst the choice of type of
PM may depend upon the aims of treatment, it appears that
patterns of movement were used less frequently in all patient
groups. Single joint movements were used most commonly,
and the majority of respondents took PMs to the end of range.
Although the reasons for these choices were not sought, it
could indicate that many physiotherapists felt more comfort-
able treating one joint at a time, perhaps for reasons related to
manual handling. As the majority of respondents took PMs to
the end of range, this finding also suggests that therapists were
utilising PMs to assess or maintain joint range of movement,
and so wanted to address joints individually.
PMs were reported to be used most commonly in the hip,
shoulder, knee, elbow and ankle. Despite these reports, it
is unclear whether taking joints to the end of range would
be possible for large joints such as the hip. The limitations
imposed by attachments such as femoral artery lines and
orthopaedic fixation are also likely to restrict attainment of
full joint range in some patients.
It is interesting to note that the hands were more commonly
treated than the feet, although the reasons for this are not
clear. This finding could suggest that maintenance of range
of movement in the hands was perceived to be more difficult
or more important than the feet, or that PMs were being used
for other reasons, including treatment of oedema.
Method of using PMs
The majority of respondents reported using PMs on a
daily basis (120/152; 78%). However, it is recognised that
232 R.C. Stockley et al. / Physiotherapy 96 (2010) 228–233
some of the closed-type questions in the questionnaire did
not allow respondents to provide as much information as they
might have liked. Several participants commented that the
frequency and use of PMs depended upon assessment find-
ings, and sometimes PMs were used for assessment purposes
alone. It was also noted that several respondents stated that
other strategies such as splinting may be utilised if required.
Although the frequency of respondents who used PMs
in different groups varied, the number of repetitions utilised
was similar for all patient groups. In all groups, except those
with other conditions, PMs were repeated a median of five
times (range 1 to 20). Although it is initially surprising that
all patient groups would receive the same number of repeti-
tions, this number could be a global estimation for all patients
within a group, when individual patients may receive greater
or fewer movements and may be affected by recall. However,
this finding could also indicate that there is little evidence on
which therapists can base their use of PMs, so they may adopt
a similar treatment approach for all patients.
As there is very little literature investigating the effects of
the number of repetitions of PMs, it is difficult to ascertain
the physiological effect of five repetitions, once daily. Tradi-
tionally, it has been proposed that the magnitude of benefit of
PMs to increase joint range and to prevent contracture forma-
tion increases with the number of repetitions [20]. Although
no minimum beneficial number has been identified, much of
the evidence has evaluated the effect of mechanical, continu-
ous passive motion over several hours, often after orthopaedic
surgery, and has not evaluated manually applied PMs or their
use in critically ill patients [[20,25,26]].
One small study has investigated the effect of PMs on
the tibialis anterior muscle of five sedated and ventilated
critically ill patients. They received three, 3-hour sessions
of continuous PMs per day. In comparison with the control
limb, a reduced rate of protein loss and decreased muscle fibre
atrophy was observed, suggesting that these processes were
attenuated by this intensity of treatment [25]. Interestingly,
the control limb received daily manual PMs for approxi-
mately 5 minutes as part of routine treatment, but this did not
appear to reduce the rate of muscle wasting. This suggests
that the frequency and duration reported by therapists in this
study may only have a minimal effect on muscle architecture
in critically ill patients.
Monitoring
Respondents were asked to select the parameters they
monitored whilst performing PMs, and to state any addi-
tional parameters that were not listed. Seventy-eight percent
(118/152) of respondents reported monitoring a range of
parameters routinely whilst performing PMs. However, it
is possible that the provision of a list of potential parame-
ters skewed responses. Heart rate and blood pressure were
monitored by most respondents, whilst intracranial pressure
and pulmonary artery pressure were monitored least often.
This is likely to be because these more invasive methods of
measurement are not required for the majority of patients, or
because equipment was not available to provide these read-
ings. Although respondents were asked to base their answers
on patients who required mandatory ventilation, respiratory
rate was monitored by over 70% (83/118). This could sug-
gest that respondents were using changes in respiratory rate
to indicate sedation level and possible discomfort, or that it
was monitored simply because it was routinely displayed.
Whilst it is likely that many patients may have had intermit-
tent mandatory ventilation and so could determine their own
respiratory rate to a certain extent, this finding could also indi-
cate that some respondents based answers upon their practice
in patients not requiring mandatory ventilation and who did
not fit the criteria for this survey.
Conclusions
This investigation is the first national survey of the use of
PMs in critically ill patients. The results indicate that PMs are
still used widely in ventilated and sedated patients, often on
a daily basis, by physiotherapists working in the NHS. The
majority of respondents reported using PMs on single joints,
most commonly the hip and shoulder, and PMs were taken
to the end of range. Cardiovascular parameters were most
commonly monitored during PMs, and respondents indicated
that PMs were repeated a median of five times on each area.
The relative consensus seen here suggests that PMs may
have a perceived or real benefit for ventilated and sedated
critically ill patients. Further work could investigate the clin-
ical reasoning process which underpins the use of PMs by
physiotherapists. Furthermore, as no studies have investi-
gated the immediate or long-term effects of PMs in critically
ill patients, it is now necessary to investigate the physio-
logical effects of PMs and their potential benefit to patient
outcome.
Acknowledgements
Rachel Bates and Tom Wilgoss are acknowledged for their
technical assistance.
Ethical approval: Manchester Metropolitan University
Research Ethics Committee (Ref. No. 0723).
Funding: Research Institute for Health and Social Change at
Manchester Metropolitan University.
Conflict of interest: None declared.
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