INVITED REVIEW

Physiotherapy for Patients on Awake Extracorporeal

Membrane Oxygenation: A Systematic Review
Massimiliano Polastri1*, Antonino Loforte2, Andrea Dell’Amore3 & Stefano Nava4
1
Medical Department of Continuity of Care and Disability, Physical Medicine and Rehabilitation, University Hospital S.Orsola-Malpighi,
Bologna, Italy
2
Department of Cardiac-Thoracic and Vascular Diseases, Cardiac Surgery and Transplantation, University Hospital S.Orsola-Malpighi,
Bologna, Italy
3
Department of Cardiac-Thoracic and Vascular Diseases, Thoracic Surgery and Transplantation, University Hospital S.Orsola-Malpighi,
Bologna, Italy
4
Department of Specialistic-Diagnostic and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, S.Orsola-Malpighi Hospital,
University of Bologna, Bologna, Italy

Abstract
Background and purpose. Extracorporeal membrane oxygenation (ECMO) is used as temporary life support in
subjects with potentially reversible respiratory/cardiac failure. The principal purpose of this review was to assess the
characteristics and potential advantages of physiotherapeutic interventions in subjects on awake ECMO support.
Methods. Seven databases were interrogated: we searched titles, abstracts and keywords using the Medical Subject Head-
ings terms ‘extracorporeal membrane oxygenation’ and ‘rehabilitation’ linked with the Boolean operator ‘AND’. Results
and conclusion. In total, 216 citations were retrieved. Nine citations satisfied our inclusion criteria and were subjected to
full-text analysis. The numbers of patients enrolled in the included studies (most of which were case series) were low
(n = 52). We found no prospective studies or randomized controlled trials. Overall, subjects on awake ECMO usually
received a combination of passive and active physiotherapy, and most achieved an acceptable degree of autonomy after
treatment. Emerging research in the field affords preliminary evidence supporting the safety of early mobilization and
ambulation in patients on awake veno-venous ECMO support. Copyright © 2015 John Wiley & Sons, Ltd.

Received 3 December 2014; Revised 30 April 2015; Accepted 24 May 2015

Keywords
extracorporeal membrane oxygenation; intensive care units; lung transplantation; physical therapy modalities; walking

*Correspondence
Massimiliano Polastri, Medical Department of Continuity of Care and Disability, Physical Medicine and Rehabilitation, University Hospital S.
Orsola-Malpighi, Via G. Massarenti 9, Bologna 40138, Italy.
Email: gbptap1@gmail.com

Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pri.1644

Introduction results, particularly in patients awaiting lung transplan-

Extracorporeal membrane oxygenation (ECMO) is
used as temporary life support in patients with poten-
tial reversible respiratory/cardiac failure (Brown,
2014). ECMO systems have improved since their devel-
opment in the 1950s and have yielded encouraging
tation (Diaz-Guzman et al., 2013) and those with se-
vere acute respiratory failure refractory to the usual
therapeutic measures (i.e. mechanical ventilation)
(Australia and New Zealand Extracorporeal Membrane
Oxygenation Influenza Investigators et al., 2009).

Physiother. Res. Int. (2015) © 2015 John Wiley & Sons, Ltd.
Physiotherapy and Awake ECMO M. Polastri et al.

While patients are on awake ECMO, they may re-
ceive physiotherapy during periods spent either
waiting for surgical procedures or while bedridden.
The inherent risks of ECMO include bleeding and in-
fections (Blum et al., 2013); thus, the technique is used
only in patients whose conditions are life-threatening
(Brown, 2014). Over the last decade, the possibility
of keeping patients awake while on ECMO, and even
allowing physical activity (i.e. walking), has attracted
increasing interest, because external support of organ
function may co-exist with bodily mobility: if in one
hand, mobilization would be desirable, in the other,
it is not always recommended (Thiagarajan et al.,
2012).
The ECMO system consists of a closed extracorpo-
real circuit, which, after proper oxygenation and tem-
perature modulation, pumps and returns the blood to
the arterial or venous system via various vessel options
according to the clinical scenario to deal with. ECMO
support can be used as a temporary bridge to organ
function recovery, bridge to candidacy, bridge to trans-
plantation, and bridge-to-bridge for severely ill patients
with refractory cardiogenic shock and/or respiratory
failure. There are two types of ECMO: veno-arterial
(VA) and veno-venous (VV). In VA ECMO, blood is
drained from the venous system and pumped to the ar-
terial. VV ECMO facilitates lung function and gas
exchanges, removing venous blood and then re-
pumping it inside the venous system. Several types of
cannulation (Table 1) can be adopted for both VA
and VV ECMO installation and running (Garcia
et al., 2010; Lafçi et al., 2014; Loforte et al., 2014).
ECMO patients are usually forced to take bed rest;
immobility and (sometimes) sedation are also indi-
cated. When such constraints endure for a long time,
associated sequelae (both physical and respiratory
complications) may further prolong hospitalization
and increase the need for additional health-care. The
possibility of physical activity while on awake ECMO
was confirmed by Garcia et al. (2010): improved gas ex-
change was reported after physical exercise and walking
in a subject awaiting lung transplantation who was on
VV ECMO support. Furthermore, awake ECMO was
applied recently in a cohort of patients affected by
bronchiolitis obliterans syndrome and used as a bridge
to re-transplantation (Lang et al., 2014).
The main purpose of this review was to assess the
potential advantages and safety of physiotherapeutic
interventions in subjects (adults and children) on VV
ECMO support.
Materials and methods
We searched seven databases: 1) The US National Library
of Medicine (PubMed); 2) Scopus; 3) EMBASE; 4)
Agency for Healthcare Research and Quality; 5) Latin-
American and Caribbean Center on Health Sciences

Table 1. Specific types of extracorporeal membrane oxygenation support

Cannulation Venous blood drainage Arterial blood return Mode of insertion Flow direction Mode

Peripheral CFV (RA) CFA Surgical or percutaneous Retrograde VA

or hybrid
Peripheral CFV (RA) Axillary artery Surgical Antegrade VA
Peripheral RIJV (SVC) CFA or axillary artery Surgical or percutaneous Retrograde or VA
or hybrid antegrade
CFV (IVC)
Peripheral RIJV or CFV RCCA Surgical Antegrade VA (paediatric)
Peripheral CFV - IVC RIJV - SVC Percutaneous — Two-site VV
Peripheral RIJV (dual lumen RIJV (dual lumen Percutaneous — One-site VV
cannula) cannula)
Peripheral CFV (IVC) CFA + RIJV (SVC) Percutaneous Retrograde VAV
Central RA AAo Surgical Antegrade VA
Central RA PAr Surgical — VV
Central RA + LA AAo Surgical Antegrade VA

RA = right atrium; CFV = common femoral vein; CFA = common femoral artery; SVC = superior vena cava; IVC = inferior vena cava; RIJV = right
internal jugular vein; RCCA = right common carotid artery; LA = left atrium; AAo = ascending aorta; PAr = main pulmonary artery; VA = veno-
arterial; VV = veno-venous; VAV = veno-arterialvenous.

Physiother. Res. Int. (2015) © 2015 John Wiley & Sons, Ltd.
M. Polastri et al.
Information; 6) Physiotherapy Evidence Database;
and 7) Scientific Electronic Library Online.
Search strategy
We searched titles, abstracts and keywords using the
Medical Subject Headings terms ‘extracorporeal
membrane oxygenation’ and ‘rehabilitation’ linked
with the Boolean operator ‘AND’. This allowed us to
obtain the maximal number of citations without overly
restricting a search that was already confined to a very
selective topic.
In fact, the use of additional keywords including
‘mobilization’, ‘physical therapy’, ‘physiotherapy’,
‘ambulatory’ and ‘awake’ did not return extra citations,
confirming the validity of our search.
Where possible, additional search filters were used to
separate citations by publication date (January 2010 to
November 2014) and language (English, French and
Italian).
Inclusion and exclusion criteria
A study had to describe the physiotherapeutic activities
of subjects on awake VV ECMO in intensive care
settings for inclusion. Subjects > or =18 years of age
were classified as adults and those younger as children.
Editorials, opinion pieces, conference proceedings
and citations that did not describe physiotherapeutic
interventions in subjects on awake VV ECMO were
excluded. All data were processed using Microsoft
Excel© (Microsoft Corporation, Redmond, WA, USA).
Results
The overall patient population initially considered in
this review consisted of 54 patients receiving
physiotherapy while on ECMO. One patient was fea-
tured in two different studies (Garcia et al., 2010;
Garcia et al., 2011) and was thus considered to be only
one case, rather than two. Another patient was
excluded because he did not receive physiotherapy
while on ECMO (Rahimi et al., 2013). The characteris-
tics of the final 52 patients are shown in Table 2. In
almost half of the patients (n = 25, 48%), ECMO
implantation was followed by tracheostomy to expedite
weaning from sedation and mechanical ventilation and
to facilitate vocal communication (Garcia et al., 2011;
Turner et al., 2011; Hayes et al., 2013; Redher et al.,
Physiother. Res. Int. (2015) © 2015 John Wiley & Sons, Ltd.
Physiotherapy and Awake ECMO
2013; Abrams et al., 2014; Turner et al., 2014; Zebuhr
et al., 2014).
Studies included
We found 216 relevant citations in three of the seven
databases (PubMed = 60, Scopus = 60 and
EMBASE = 96). Eleven citations met our inclusion
criteria and were subjected to full-text analysis. As
shown in Figure 1, nine studies were included in our fi-
nal revision. All included citations (Garcia et al., 2010;
Garcia et al., 2011; Turner et al., 2011; Hayes et al.,
2013; Rahimi et al., 2013; Redher et al., 2013; Abrams
et al., 2014; Turner et al., 2014; Zebuhr et al., 2014) de-
scribed physiotherapeutic procedures performed in
acute care settings, including exercise and postural
changes (Table 3).
No prospective study or randomized controlled trial
was retrieved; three of the nine studies (33%) were of a
retrospective cohort design, and the remainder were
case reports or case series (67%). No case series
included more than three subjects, and the largest
study included 35 subjects.
In our analysis, we included adults and children;
treatment modalities did not differ since, while on
awake ECMO, patients achieved in-bed movements,
sitting and/or ambulation in both populations.
Physiotherapeutic intervention
Physiotherapy was commenced as soon as possible
(within 2–5 days) in almost all patients, and this was
clear in all studies (Turner et al., 2011; Rahimi et al.,
2013; Redher et al., 2013; Abrams et al., 2014). Mobili-
zation (passive and active movements and postural
changes), in-bed positioning (either sitting or upright)
and ambulation were the most commonly used
physiotherapeutic interventions in subjects undergoing
awake ECMO (Table 3).
Discussion
To the best of our knowledge, this is the first review ex-
ploring the characteristics and potential advantages of
physiotherapeutic interventions in subjects (adults
and children) on VV ECMO support. We sought to ob-
tain an overview of the physical activities appropriate
for such patients, as exemplified in the existing
literature.
Physiotherapy and Awake ECMO M. Polastri et al.

Table 2. Characteristics of patients (n = 52)

Diagnosis at
Ambulating while the time of APACHE II* APACHE III*
n, (%) Mean age (yrs) on ECMO n, (%) PT sessions (n)* ECMO initiation (n) (mean score) (mean score)

Adults 47, (90) 42.8 - - - - -

Pediatrics 5, (10) 13.8 - - - - -
Female 32, (62) - - - - - -
Male 20, (38) - - - - - -
BTLT 33, (63) 29.6 20, (61) 11.4 CF = 18, ILD = 7, - -
COPD = 3, IPF = 3,
PF = 1, PAH = 1
BTR 19, (37) 45.1 6, (24) 11.3 ARDS = 11, COPD = 4, - -
PAH = 4
24.3±7.8 73.7±27.5

ECMO = extracorporeal membrane oxygenation; PT = physiotherapy; APACHE = Acute Physiology and Chronic Health Evaluation* (data are
obtained from the studies where available); BTLT = bridge to lung transplantation; BTR = bridge to recovery; CF = cystic fibrosis; ILD = interstitial
lung disease; COPD = chronic obstructive lung disease; IPF = interstitial pulmonary fibrosis; PF = pulmonary fibrosis; PAH = pulmonary arterial
hypertension; ARDS = acute respiratory distress syndrome.

Figure 1. Flowchart
The rehabilitation needs of individuals undergoing
ECMO have become better understood over the past
decade. The limited numbers of subjects in each of
the studies that we evaluated confirmed that our topic
was very specialized. Only one study included a rela-
tively high number of patients, emphasizing the
increase in attention paid to awake ECMO procedures
and associated physiotherapeutic interventions
(Abrams et al., 2014).
Safety issues
Participation in active physical therapy while on
ECMO is a viable option, but co-operation between
all professionals involved is necessary to guarantee
safety and therapy suitability in all such patients
(Rahimi et al., 2013). Cannulae dislocation is a major
risk factor in patients mobilized while on ECMO;
ambulation was facilitated in patients with jugular
cannulation by placing dual-lumen catheters. Although
ambulation in patients with femoral venous ECMO
cannulae is considered a high-risk intervention, in the
study by Abrams et al. (2014), the authors described
their experience in achieving standing or ambulation
in two patients.
Physical therapy has been shown to be both safe and
feasible in intensive care unit (ICU) survivors and in
those with respiratory failure (Bailey et al., 2007;
Schweickert and Kress, 2011). However, in-bed posi-
tioning and mobilization must be implemented with
caution to avoid cannulae displacement in ECMO pa-
tients. Strictly speaking, passive movement is often the
first physiotherapeutic step in ICU patients, in efforts
to maintain joint mobility, prevent muscular contrac-
ture, maintain the extensibility of soft tissues and gener-
ally preserve function (Wiles and Stiller, 2010; Stockley
et al., 2012).
Many authors agree that mobilization and manage-
ment of subjects undergoing ECMO should be
performed by a multidisciplinary team featuring an anes-
thesiologist, surgeon, perfusionist, physiotherapist, nurse,
respiratory therapist and intensive care physicians

Physiother. Res. Int. (2015) © 2015 John Wiley & Sons, Ltd.
M. Polastri et al. Physiotherapy and Awake ECMO

Table 3. Summary of physiotherapeutic activities

Authors (year) Study design Duration of ECMO Physiotherapeutic intervention

(number of subjects) (days)

Turner et al. (2014) Case report (1) 51 Sitting in a chair position in bed and ambulation (12 m)
Zebuhr et al. (2014) Case report (1) 49§ Passive physical therapy to active rehabilitation programme
Abrams et al. (2014) Retrospective cohort (35) BTLT = 18.7* In-bed active-assisted range of motion, maintaining sitting
BTR = 9.1* in bed and sitting at the edge of the bed, standing and
ambulation (18 subjects had walked a median distance of
53 m). Two subjects walked a mean distance of 670 m
Hayes et al. 2013 Case report (1) 21 Active rehabilitation
Redher et al. (2013) Retrospective cohort (5) 8.6* Four patients walked (among them, two subjects walked
213 and 396 m, respectively). The mean walked distance at
discharge was 780 m. One patients received resistance
exercises and was sitting at the edge of the bed
Rahimi et al. (2013) Case series (2) 8* Supine therapeutic exercises, active in-bed cycling and
sitting at the edge of the bed with assistance
Turner et al. (2011) Case series (3) 9.7* Strengthening exercises, increasing mobilization, march in
place and ambulation (one subject walked 213 m)
Garcia et al. (2011) Retrospective cohort (3) 20* Active rehabilitation and ambulation
Garcia et al. (2010) Case report (1) — Ambulation
§
days on veno-venous ECMO (patient initially underwent veno-arterial ECMO for 28 days: overall ECMO duration 77 days).
*mean.
ECMO = extracorporeal membrane oxygenation; BTLT = bridge to lung transplantation; BTR = bridge to recovery.

(Turner et al., 2011; Thiagarajan et al., 2012; Rahimi et al.,
2013; Abrams et al., 2014; Zebuhr et al., 2014).
Respiratory therapy
Transition from respiratory treatment to a
physiotherapeutic programme with greater focus on
motor issues should be linked to progress in clinical
status. The study by Fiddler and Williams (2000) em-
phasized the importance of respiratory therapy when
proposed to treat or prevent pulmonary complications
in ECMO patients; in-bed positioning and postural
exercises are vital components of such treatments,
promoting lung ventilation and removal of secretions.
Furthermore, it has been found that chest physiotherapy
plays an important role in order to facilitate secretion
clearance and lung function for a patient while on
ECMO (Cork et al., 2014). In a series of candidates
awaiting lung transplantation, the post-transplantation
duration of ventilation and the postoperative ICU stay
were shorter in those undergoing rehabilitation while
on ECMO (Thiagarajan et al., 2012).
Movements
Both passive and active movements should be consid-
ered in subjects on awake ECMO, which is clear from
the evaluated studies (Turner et al., 2011; Rahimi
et al., 2013; Abrams et al., 2014; Zebuhr et al., 2014).
A recent study described for the first time active reha-
bilitation in an 8-year-old boy on VV ECMO support
for the recovery from acute respiratory distress
syndrome (Zebuhr et al., 2014). However, when no
other type of exercise is possible, in-bed positioning
serves as a preventative activity. In this regard, the abil-
ity to maintain a sitting position allows patients to per-
ceive environmental characteristics and to make
postural changes: sitting upright in the bed is a viable
option in order to facilitate patient’s activity (Hayes
et al., 2013).
Although it may be obvious, independent meal-
taking is of great importance in patients undergoing
awake ECMO. Oral feeding facilitates medication and
hydration; body movements associated with eating are
rehabilitative per se in such patients.
Ambulation
From the included studies, ambulation was one of
the described activities (Garcia et al., 2010; Garcia
et al., 2011; Turner et al., 2011; Redher et al., 2013;
Abrams et al., 2014; Turner et al., 2014). The first
study on this topic showed that ambulation and
treadmill walking were feasible in an adult affected

Physiother. Res. Int. (2015) © 2015 John Wiley & Sons, Ltd.
Physiotherapy and Awake ECMO
by respiratory failure (with severe chronic obstructive
pulmonary disease) who was on VV ECMO support
(using a single dual-lumen catheter) as a bridge to
transplantation (Garcia et al., 2010).
Depending on a patient’s medical state, ambula-
tion—even if assisted—is a desirable goal in ICU;
this involves the activation of many physical and
neurological functions. Indeed, contact with a sur-
face transmits many proprioceptive signals to the
nervous system, and maintenance of the upright
position requires the active involvement of anti-
gravity muscles. This positively affects cervical
spine mobility, as prolonged supine positioning
may weaken the neck muscles, rendering it difficult
to hold the head up. In addition, one muscle group
that benefits greatly from standing is the gluteus,
which maintains the pelvis in a horizontal position
and permits hip extension when the body is
subjected to an axial load. Walking in the ICU,
when this is both appropriate and feasible, is a
rehabilitative challenge.
Limitations
The low number of patients enrolled and the nature of
the published studies (mostly case series) rendered
meta-analysis impossible. The quality of the studies in-
cluded could be considered a limitation due to their
non-experimental nature. In addition, with such a
small number of patients, one could argue that physio-
therapy for ambulatory ECMO is limited to a very
restricted class of subjects and it cannot be generalized
into a wider context. In this regard, findings of our
analysis are closely related to the nature of the research
that is performed up to now: because no experimental
studies have been found on the topic, we cannot affirm
that physiotherapeutic treatment is feasible in all
ECMO patients. Despite these limitations, the present
review answered our question on appropriateness and
safety of the physiotherapeutic intervention in subjects
on awake ECMO.
Clinical implications
We found a common thread in the studies evaluated, as
this was a special focus on ambulation. In a high pro-
portion of patients included in the present review,
effective breathing was confirmed via tracheostomy
while on awake ECMO.
M. Polastri et al.
Some medical conditions, including haemorrhage,
unstable arrhythmia, severe thrombocytopenia, hemo-
dynamic instabilities requiring drugs at high doses
and hypoxemia resistant to extra oxygen support, are
dangerous and prohibit the use of physiotherapeutic
treatment (Abrams et al., 2014).
Another interesting aspect of our evaluation was the
possibility to assess the motor performance of ambulat-
ing subjects by calculating the distances walked (Turner
et al., 2011; Redher et al., 2013; Abrams et al., 2014;
Turner et al., 2014; ). This was performed in a cohort
of critical patients undergoing pulmonary endarterec-
tomy, and it served as a simple, inexpensive and
reliable measure of outcomes in the immediate postop-
erative period (Polastri et al., 2013).
In synthesis, from the included studies, it could be gath-
ered that potential advantages of awake and ambulatory
ECMO are mainly related to motor and functional factors:
by means of ambulation, exercises, sitting, in-bed posi-
tioning and other interventions, (Table 3) patients main-
tained and/or improved their autonomy while on ECMO.
Conclusion
This review has emphasized the important roles played
by professionals in the treatment of awake patients on
VV ECMO. High-level technical skills along with cer-
tain personal characteristics (willingness to work in a
team, knowledge of ECMO systems and adherence to
safety protocols) are essential. Emerging research in
the field affords preliminary evidence supporting the
safety of early mobilization and ambulation in patients
on awake VV ECMO support.
Awake ambulatory ECMO is an emerging topic. It
seems that this practice, when feasible, yields optimal
results in terms of prevention and treatment of
potential complications associated with prolonged
in-bed immobility in critical patients.
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