Online Review Articles
Occupational Therapy in the ICU: A Scoping
Review of 221 Documents
F. Aileen Costigan, OT Reg (Ont), PhD1; Mark Duffett, RPh, PhD2,3; Jocelyn E. Harris, OT Reg (Ont), PhD4;
Susan Baptiste, OT Reg (Ont)4; Michelle E. Kho, PT, PhD1,4
Objectives: Occupational therapists have specialized expertise
to enable people to perform meaningful “occupations” that sup-
port health, well-being, and participation in life roles. Given the
physical, cognitive, and psychologic disability experienced by ICU
survivors, occupational therapists could play an important role
in their recovery. We conducted a scoping review to determine
the state of knowledge of interventions delivered by occupational
therapists in adult ICU patients.
Data Sources: Eight electronic databases from inception to
05/2018.
Study Selection: We included reports of adult patients receiving
direct patient care from an occupational therapist in the ICU, all
study designs, and quantitative and qualitative traditions.
Data Extraction: Independently in duplicate, interprofessional team
members screened titles, abstracts, and full texts and extracted
1
Physiotherapy Department, St. Joseph’s Healthcare, Hamilton, ON,
Canada.
2
Department of Pediatrics, Faculty of Health Science, McMaster Univer-
sity, Hamilton, ON, Canada.
3
Department of Health Research Methods, Evidence, and Impact, McMas-
ter University, Hamilton, ON, Canada.
4
School of Rehabilitation Science, Faculty of Health Science, McMaster
University, Hamilton, ON, Canada.
Supplemental digital content is available for this article. Direct URL cita-
tions appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s website (http://journals.lww.com/
ccmjournal).
A Knowledge Synthesis Grant from the Canadian Frailty Network (for-
merly Technology Evaluation in the Elderly Network) funded this study (KS
2013-13).
Dr. Harris’s institution received funding from the Canadian Institutes of
Health Research (CIHR). Dr. Baptiste disclosed that they received Re-
search Knowledge Synthesis Grants in 2015 that provided the founda-
tional funds to complete this study; the funds were held at McMaster
University, Faculty of Health Sciences. Dr. Duffett was funded by a Fellow-
ship from the CIHR and Hamilton Health Sciences Early Career Award
during this project. Dr. Kho’s institution received funding from Canadian
Frailty Network (formerly Technology Evaluation in the Elderly Network).
Dr. Kho holds a Canada Research Chair in Critical Care Rehabilitation and
Knowledge Translation from the CIHR. Dr. Costigan has disclosed that
she does not have any potential conflicts of interest.
For information regarding this article, E-mail: khome@mcmaster.ca
Copyright © 2019 by the Society of Critical Care Medicine and Wolters
Kluwer Health, Inc. All Rights Reserved.
DOI: 10.1097/CCM.0000000000003999
e1014 www.ccmjournal.org December 2019 • Volume 47 • Number 12
Copyright © 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
report and intervention characteristics. From original research ar-
ticles, we also extracted study design, number of patients, and
primary outcomes. We resolved disagreements by consensus.
Data Synthesis: Of 50,700 citations, 221 reports met inclu-
sion criteria, 74 (79%) published after 2010, and 125 (56%)
appeared in critical care journals. The three most commonly re-
ported types of interventions were mobility (81%), physical reha-
bilitation (61%), and activities of daily living (31%). We identified
46 unique original research studies of occupational therapy inter-
ventions; the most common study research design was before-
after studies (33%).
Conclusions: The role of occupational therapists in ICU rehabil-
itation is not currently well established. Current interventions in
the ICU are dominated by physical rehabilitation with a growing
role in communication and delirium prevention and care. Given
the diverse needs of ICU patients and the scope of occupational
therapy, there could be an opportunities for occupational thera-
pists to expand their role and spearhead original research investi-
gating an enriched breadth of ICU interventions. (Crit Care Med
2019; 47:e1014–e1021)
Key Words: critical illness; intensive care units; occupational
therapy; recovery of function; rehabilitation; ventilators, mechanical
O
ver the past decade, postintensive care survival rate
has improved (1); however, survivors experience new
physical, cognitive, and mental health impairments
(2, 3). The goal of rehabilitation is promote skill gain and re-
sumption of life activities by targeting impairments, activity
limitations, and participation restrictions in those with injury
or illness (4). In the ICU, rehabilitation involving physical ther-
apists (PTs) and occupational therapists (OTs) can improve
functional independence upon hospital discharge (5). Yet, pre-
vious research documented underutilized involvement of PT
and OT led interventions in the ICU (6).
Recent studies reported combined PT and OT roles in crit-
ical care (e.g., PT/OT orders [7], PT/OT provided mobility [8],
dedicated PT/OT therapy in ICUs, without distinguishing be-
tween professions [9]), however, PTs and OTs offer distinct ex-
pertise for critically ill patients. Physical therapy assists patients

after injury, illness, or disability through movement and exer-
cise, manual therapy, education, and pain management (10).
Occupational therapy, less understood, enables engagement
in everyday living through “doing” for those recovering from
illness, injury, or learning to live with disability. OTs support
patients performing needed and individually meaningful
“occupations” that affect health, well-being, and participation
in life roles (11). Occupational therapy interventions center
upon the transactional relationships between an individual
(Person) in situ (Environment), doing something needed, ex-
pected, or desired by the individual (the Occupation). This
P-E-O model guides the work of OTs in any setting (12). In
critical care, this could translate into interventions to target
the physical, cognitive, and emotional/psychologic abilities
of the patient (e.g., mobility, orientation, coping skills), and
characteristics of both the ICU environment (e.g., physical
set-up, noise, organizational culture) and the tasks the patient
performs in the ICU (e.g., self-care activities, communication
with staff members, socializing with family members).
Occupational therapy has existed in selected ICUs over
some time. For example, in 1986, Affleck et al (13) reported on
the utility of an OT in the ICU to assist in ameliorating nega-
tive outcomes of prolonged bed rest, sensory deprivation and
stress, and prolonged medical ventilation. Nonetheless, wide-
spread implementation of occupational therapy ICU services
is sparse, inconsistent, and largely dependent upon relation-
ships with team members informed about the added value of
including an OT in intervention plans. We conducted a scop-
ing review to determine the current state of knowledge related
to therapy interventions delivered by OTs in the ICU and to
identify any potential for role enrichment and expansion.
MATERIALS AND METHODS
Our research question was, “What are the reported roles of
OTs for adult patients in the ICU?” We conducted our review
according to the methods of Arksey and O’Malley (14), revised
recommendations by Levac et al (15), and reported our re-
search per Colquhoun et al (16) and the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA)
Extension for Scoping Reviews (17).
Search Strategy
A health research informatics expert helped develop search
strategies for these databases from inception to May 2018:
MEDLINE, Cumulative Index to Nursing and Allied Health
Literature, Web of Science, Scopus, Cochrane Library, Edu-
cation Resources Information Center, Social Science Citation
Index, and the Social Science Research Network. The search
combined keywords and subject headings for the concepts
of “intensive care” and “occupational therapy” (Appendix A,
Supplemental Digital Content 1, http://links.lww.com/CCM/
E919).
Inclusion and Exclusion Criteria
We included all documents reporting direct patient care inter-
ventions conducted actively by an OT in critically ill adults (≥
Critical Care Medicine www.ccmjournal.org e1015
Copyright © 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Online Review Articles
18 yr) to document the current state of occupational therapy
in the ICU. We defined an “active role” as any intervention
conducted by an OT. We used the authors’ descriptions of the
ICU setting (18). Documents included English language full-
text reports of quantitative and qualitative research traditions
and study designs (e.g., original research, narrative and sys-
tematic reviews, protocol papers, clinical practice guidelines,
descriptions of care, editorials). We also included surveys of
practice in the ICU. We excluded documents of medical or
pharmacologic interventions (outside scope of occupational
therapy practice), interventions started after the ICU, or
interventions directed toward families or ICU staff.
Document Selection and Data Abstraction
Pairs of team members independently screened titles, abstracts,
and full-text documents in duplicate. We resolved disagree-
ments by consensus. We used Distiller SR, an online systematic
review citation and data management system (2014 Evidence
Partners, Ottawa, ON, Canada), for document selection and
data abstraction.
A multidisciplinary team developed a document selection
and data abstraction manual and tested a data collection form
(Appendix B, Supplemental Digital Content 2, http://links.
lww.com/CCM/E920). This team included four experienced
OTs (F.A.C., J.E.H., S.B., J.M.), three ICU PTs (M.E.K., N.S.,
L.P.), one physical therapy student (M.C.), a health sciences
student (D.M.), a research assistant (S.P.) and an ICU research
methodologist (M.D.). As we identified potentially eligible
reports, the four OTs categorized the interventions. To test the
document selection and data abstraction materials, five team
members (M.D., J.E.H., S.B., M.E.K., F.A.C.) reviewed 5–10
reports independently, discussed the results and revised mate-
rials as appropriate.
We abstracted the following data from each included report:
report characteristics (e.g., year and country of publication,
journal focus [i.e., practice area], journal title, journal pro-
fessional audience, report type [e.g., review, original research,
editorial]) and intervention characteristics (i.e., ICU setting,
intervention description, other healthcare personnel involved).
For original research reports, we also abstracted study design,
number of ICUs, number of patients, ICU setting, comparison
interventions, and outcomes. We resolved disagreements by
consensus.
Statistical Analysis
All binary data are reported as counts and percentages, and
continuous data as median and interquartile range (IQR). We
conducted a linear regression to determine differences in pub-
lication rates over time using R Version 3.4.2 (R Foundation
for Statistical Computing, Vienna, Austria) and p value of less
than 0.05 as the criterion for statistical significance.
RESULTS
We identified 50,700 potentially relevant reports; 634 stud-
ies reported interventions within the scope of an OT but
performed by another health professional. Two-hundred
Costigan et al

125 (56%) and 36 (16%) reports, respectively. Only 14 (6%)

appeared in occupational therapy-specific journals. The three
most common types of reports were reviews (112 [51%]),
original research (63 [29%]), and editorials, commentaries, or
appraisals of original research (27 [12%]).

Reported Occupational Therapy Interventions

We identified 21 types of occupational therapy interventions
and developed six categories (physical, social or emotional, en-
vironmental, sensory, cognitive, and communication). Figure 4
presents the reports of each intervention by publication type.
Most (144 [65%]) reports identified more than one interven-
tion, with a median (IQR) of 1 (1–3) interventions. The three
most commonly reported interventions were mobility (180
[81%]), physical rehabilitation (134 [61%]), and activities of
daily living (69 [31%]).

Figure 1. Flow diagram of included reports. OT = occupational therapist.
twenty-one met inclusion criteria (Fig. 1). Figure 2 shows the
number of reports published by year; 174 (79%) were pub-
lished since 2010 and the number of publications per year
increased significantly over time (p < 0.001). Table 1 summa-
rizes the characteristics of included reports. Reports were from
18 different countries, most commonly the United States (151
[69%]), with 215 (98%) from high-income countries (Fig. 3).
Critical care and rehabilitation-focused journals published
50
Publication type
Original research
40
Number of Publications
Original Research—Patients
Fifty original research reports identified an active intervention
performed by an OT and included 13 (26%) which explic-
itly listed an OT author. Reports represented 46 unique stud-
ies (Table E1, Supplemental Digital Content 3, http://links.
lww.com/CCM/E921). Studies were most often conducted in
medical (21 [46%]), neurologic/ neurosurgical (13 [28%]),
or surgical ICUs (9 [20%]). These included three randomized
clinical trials (RCTs) (7%), 10 cohort studies (22%), 15 before-
after studies (33%), two cross-sectional studies (4%), five case
series (11%), 10 case reports (22%), and one (2%) financial
model. Studies enrolled 25,863 patients (median per study, 76;
IQR, 5-169), with most including 100 or fewer patients (25
[54%]) and 3 (7%) including over 1,000 patients. The top five
interventions were physical rehabilitation (39 [85%]), mobility
(38 [83%]), activities of daily living (16 [35%]), augmentative
and alternative communication (11 [24]%), and seating and
wheelchair (8 [17%]). Only
four of 46 studies (9%) re-
ported interventions delivered
exclusively by OTs. The re-
maining 42 studies (91%) re-
ported interventions delivered

Other publication type

by OTs and other profession-
als, most commonly PTs (38
30 [83%]), nurses (26 [57%]),
respiratory therapists (11
[24%]), and speech-language
20 pathologists (10 [22%]).
Reports investigated 10
types of main outcomes (Table
10 E1, Supplemental Digital
Content 3, http://links.lww.
com/CCM/E921). The most
0 commonly reported out-
1980 1985 1990 1995 2000 2005 2010 2015 comes were health/functional
Year of publication status (31 [62%], e.g., patient
health, patients’ perceived
Figure 2. Overview of included reports by year. health, activity performance);

e1016 www.ccmjournal.org December 2019 • Volume 47 • Number 12

Copyright © 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
 Online Review Articles

Overview of Included Documents

TABLE 1. hospitalization outcomes (26 [52%], e.g., ICU or hospital
Reporting an Active Role of Occupational length of stay, patient mortality, discharge disposition); feasi-
bility/ implementation (20 [40%], e.g., type, duration, number
Therapists in the ICU
of patients); safety/adverse events (13 [26%]); and mechanical
Documents, ventilation status (12 [24%]).
Characteristics n = 221, n (%)

Countries Original Research—Health Professionals

We identified nine surveys (19–27) and four qualitative stud-
  United States 151 (69)
ies (28–31) that included OT’s perspectives on direct patient
 Australia 12 (5) care in the ICU. One survey ([19] 11%) explicitly targeted OTs
 Canada 12 (5) (19). Surveys investigated factors affecting the implementation
  United Kingdom 10 (5) of intervention packages provided at least in part by OTs in
the ICU including the Awakening and Breathing Coordination,
 Germany 8 (4)
Delirium monitoring/management, Early exercise/mobility
 Japan 5 (2) (ABCDE) bundle (32) (4 [44%]) (21–23, 26); early mobility
 Other a
16 (7) programs (3 [33%]) (20, 24, 27); or general rehabilitation pro-
Journal focus grams (2 [25%]) (19, 25).
  Critical care 125 (56) All qualitative studies (4 [100%]) (28–31) included OTs
and other health professionals. Methodologies included focus
 Rehabilitation 60 (27)
groups (2 [50%]) (28, 31), interviews (2 [50%]) (29, 30), and
 Other 36 (16) participant observation (1 [25%]) (31). Studies investigated
Journals factors affecting the implementation of general rehabilitation
  Critical Care Medicine 24 (11) programs (29, 30), the ABCDE bundle (28), and the experi-
ence of providing augmentative and alternative communica-
  Journal of Critical Care 10 (5)
tion services (31) in the ICU.
  Critical Care 7 (3)
  Chest 6 (3)
DISCUSSION
  Critical Care Clinics 6 (3) In this comprehensive scoping review of OT provided inter-
  Critical Care Nursing Quarterly 6 (3) ventions for adults in the ICU, we included 211 unique publica-
  Journal of the Intensive Care Society 6 (3) tions published between 1984 and 2018. Our work documents
the trajectory of occupational therapy in the ICU over the past
  Physical Therapy 6 (3)
35 years and lays the foundation for future role development
 Otherb 150 (68) and evaluation.
Primary journal audience The increase in publications since 2010 suggests grow-
 Medical 130 (59) ing interest in the contribution OTs can make to survivors’
recovery—but the relative paucity of original research stud-
 Nursing 39 (18)
ies among these publications underscores the need for future
 Physiotherapy 19 (9) rigorous evaluation. We identified nearly twice the number
  Occupational therapy 14 (6) of reviews compared with original research. Our results are
 Other 19 (9) consistent with a recently published a systematic review of
Publication type
occupational therapy interventions on functional outcome
measures for adults in the ICU (33). The authors identi-
 Review 112 (51)
fied eight unique studies enrolling 985 patients, published
  Narrative review 86 (39) from inception to 2016, one of which described the occupa-
  Systematic review 26 (12) tional therapy interventions and explicitly investigated oc-
  Original research 63 (29) cupational therapy separate from physical therapy (34). Our
scoping review updates and expands the current literature
  Studying patients 50 (23)
by summarizing across all publication and outcome types to
   Studying health professionals 13 (6) provide a rich description of the current reported roles of
  Editorial, commentary, or appraisal 27 (12) OTs in ICUs.
  Description of a practice model 10 (5) The need for physical rehabilitation for those who are criti-
  Study protocol 3 (1)
cally ill has been well documented (35–38). We found that most
of the occupational therapy roles reported included mobility
 Other 6 (3) and physical rehabilitation (Fig. 4), likely influenced by the
Other includes 12 countries, each publishing one to four documents each.
a
seminal RCT of physical and occupational therapy in the ICU
Other includes 64 journals, each publishing one to five documents each.
b
(5). In this study, more of the patients who received physical

Critical Care Medicine www.ccmjournal.org e1017

Copyright © 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Costigan et al
Figure 3. Map of included reports by country of publication.
and occupational therapy started within 1.5 days of intubation
were functionally independent in walking and six key activities
of daily living at hospital discharge. The influence of this article
highlighted the importance of occupational therapy within the
ICU environment; however, it could also narrow team mem-
bers’ and researchers’ view of OT contributions.
Mobility and physical rehabilitation represent only part of
the scope of practice of OTs, who are ideally prepared to help
ICU survivors address the cognitive and psychologic needs
encountered during an ICU experience (2, 38–40). The cur-
rent roles of OTs in critical care reported in the literature do
not reflect the breadth or depth of contributions OTs can make
in enhancing recovery for critically ill patients. Given the cog-
nitive and psychologic distress experienced by critically ill sur-
vivors, our results highlight important gaps and opportunities
for further research and evaluation. Future ICU occupational
therapy could include participation in self-care activities (e.g.,
bathing, grooming, hygiene, feeding), cognitive interventions
(e.g., activities that promote orientation to person, place, time
and executive functioning), and psychologic interventions to
reduce depression and anxiety (e.g., resumption of self-care,
introduction of leisure and social activities, modifying physical
and social environment).
Two potential core skill sets of OTs in the ICU include
cognitive interventions and use of assistive technology; this
compliments the recognized key area of cognition (41) and
delirium prevention and care (26, 32, 34). Patients may re-
quire the full range of occupational therapy services including
mental health assessments and interventions, such as cop-
ing with post-traumatic stress disorder (42, 43), and helping
e1018 www.ccmjournal.org December 2019 • Volume 47 • Number 12
Copyright © 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
patients and families cope with the multifaceted implications
of critical illness recovery (44, 45). The value of assistive tech-
nology for communication needs in the ICU environment has
been recognized for many years with a recent resurgence of
interest and application (46–48). One critical example of the
application of assistive technologies shows how an OT can
ameliorate the frustration of being unable to make one’s needs
understood when intubated or ventilated. These examples il-
lustrate clearly the bio-psycho-social (societal) nature of the
occupational therapy lens.
In addition to frequently focusing on mobility and phys-
ical rehabilitation, almost all (91%) of original research stud-
ies reported multidisciplinary (OT with other professions)
interventions.
Although reflecting the multidisciplinary nature of critical
care clinical practice, there is an urgent need for OTs to engage
in and lead the academic discussion and study of their role,
particularly by spearheading original research. For example,
we identified few intervention studies, and only one RCT, led
by OTs (34). The scope and audience of the journals pub-
lishing this research is also important. Over half of the docu-
ments were published in critical care or medical journals, and
fewer in rehabilitation journals, posing a potential knowledge
translation gap—for rehabilitation clinicians to understand
the scope of contributions of OTs in critical care. However,
publishing in critical care journals facilitates communica-
tion of the OT role to key team members such as physicians
and nurses, potentially allowing an easier integration of OTs
onto the ICU team. A priority for dissemination of the poten-
tial contributions of OTs in critical care includes increasing
 Online Review Articles

Physical
Mobility
Physical rehabilitation
Activities of daily living
Feeding/eating/swallowing
Splinting
Skin care
Environmental
Augmentative and alternative communication
Seating and wheelchair
Environmental modifications/adaptations
Assistive devices
Cognitive
Delirium prevention and care
Cognitive assessment and intervention
Social or emotional
Mental health/Psychosocial/Coping
Family support/Goal setting
Sensory
Sensory stimulation
Music Therapy
Other types
Publication type
Discharge planning
Original research
Sleep
Education Other publication type
Other
0 25 50 75 100 125 150 175
Number of Publications
Figure 4. Reported interventions by occupational therapists in the ICU. aExamples of other include diary, pet therapy, imagery, aromatherapy, thera-
peutic touch.

exposure within rehabilitation-specific publications, confer-
ences, and other educational opportunities such as educational
rounds and workshops.
Our study has limitations. We searched databases from in-
ception to May 2018; documents published after this date are
not included in this review. We excluded non-English pub-
lications, thus potentially excluding documents from other
jurisdictions. Four experienced OTs, diverse in age and prac-
tice area, identified occupational therapy interventions, but a
different team may have identified different priorities. We fo-
cused solely on the role of occupational therapy within direct
patient care in the ICU as we believed these had the greatest
and most immediate potential for practical enrichment or en-
hancement. Clearly, opportunities exist for OTs to engage with
ICU survivors, families and care providers to improve patient
outcomes post-ICU, in the hospital, rehabilitation setting, and
in the community (35, 49). Finally, we did not assess the effec-
tiveness of OT interventions in the ICU.
Our study has several strengths. We involved a multidiscipli-
nary team at all stages of the project, developing depth and breadth
of the research question, evolution of definitions, and refinement
of data extraction. We used objective criteria and a pretested data
abstraction manual to optimize reproducibility and transparency.
We selected citations and completed data abstraction independ-
ently and in duplicate, minimizing potential error and bias.
CONCLUSIONS
There is increasing global awareness of active ICU roles for
occupational therapy (50). Our findings demonstrated an
interest in services occupational therapy can provide. Orig-
inal research investigating active occupational therapy inter-
ventions is sparse and was not typically published by OTs.
Findings from this study will facilitate the description of the
occupational therapy scope of practice in critical care, and pro-
vide a foundation for future research projects, ideally initiated
and led by an OT together with the ICU team. The majority
of interventions currently performed by OTs in critical care
involved physical rehabilitation. However, other significant
contributions for occupational therapy in areas of activities of
daily living, cognition, psychosocial input, mental health, and
environmental interventions are possible and importantly can
facilitate patient-centered care and recovery.

Critical Care Medicine www.ccmjournal.org e1019

Copyright © 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Costigan et al
ACKNOWLEDGMENTS
We are grateful to the following people for their contributions
to our scoping review: Data abstractors Marissa Constand
(PT), Jennifer MacKendrick Weber (OT), Laurel Patterson
(PT), Stacey Priest, and Noreen Syed (PT) for study identifi-
cation and data abstraction; Alexander Molloy and Heather
O’Grady for assistance with study retrieval; and Carrie Price
(MLS) for developing the search strategy.
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