APTA: Physical Therapy Guide to Post-Intensive Care Syndrome
Post-intensive care syndrome, or PICS, is a condition that describes the physical, mental health, and/or cognitive problems that may develop after someone has spent time in a hospital’s intensive care unit. These problems may include difficulty with familiar tasks, such as walking, climbing stairs, getting dressed, or preparing a meal. PICS can sometimes make it difficult to return to everyday responsibilities, such as driving or working. These problems can persist for weeks, months, and sometimes years. Physical therapists help people with PICS improve their strength, stamina, and balance, and help them restore their ability to perform daily activities.
What Is Post-Intensive Care Syndrome?
Being in an ICU is a difficult experience that may take a toll on your body and mind. If you have spent time in a hospital ICU, you may experience problems with your physical abilities, your mental health, and/or your ability to think (cognition). When a person has some or all of these problems after an ICU stay, they are experiencing post-intensive care syndrome, or PICS.
Physical problems related to PICS can include:
- Muscle weakness.
- Breathing problems.
- Trouble walking.
- Struggling to care for yourself, drive, or work.
Mental health problems can include:
- Posttraumatic stress disorder, or PTSD.
- Trouble sleeping.
Cognitive problems can include:
- Difficulty remembering things.
- Trouble concentrating or thinking clearly.
- Difficulty completing tasks.
People have a higher risk for developing PICS if they:
- Have spent more than two days in the ICU.
- Needed a mechanical ventilator to help them breathe.
- Experienced delirium.
The severity and symptoms of PICS can vary widely. Most people who have been in an ICU will have problems with movement, thinking, and/or mental health. These problems can be mild to serious and may last from a few weeks or months to even years. PICS symptoms can be frustrating, both for the person experiencing them, and for their families.
The family also may experience anxiety, depression, or stress while caring for a person with PICS. If a member of the family experiences these symptoms, it is known as PICS-Family.
How Does It Feel?
People experiencing PICS may have a variety of symptoms that can vary widely in severity. These symptoms can impact your ability to complete activities of daily living and may affect your ability to live independently. PICS also may make it hard for you to work, care for your family, or return to activities you enjoy. These difficulties may be due to the physical, cognitive, and/or mental health problems associated with PICS noted above. Below are some examples of how a person who has PICS may feel in daily life:
Physical problems (weakness, shortness of breath, fatigue, and balance problems) may cause difficulty with:
- Walking in the community or even just in your home.
- Going up and down stairs.
- Getting showered and dressed.
- Grocery shopping and preparing meals.
- Playing sports or participating in leisure activities.
Mental health problems (anxiety, depression, PTSD) may cause you to feel:
- As if you don’t want to get out of bed in the morning.
- A sense of doom.
- Afraid to leave your home.
- Fearful of being rehospitalized.
- Frightened by vivid nightmares or memories once you are home.
Cognitive problems (difficulty remembering, concentrating, and completing tasks) may feel like:
- It is harder to concentrate on work, reading, or other activities.
- Remembering things that you did not have trouble remembering before the hospitalization is a challenge.
- Thinking through complex tasks like cooking is frustrating.
- Planning your day is difficult.
Writing about your problems in a diary can help you and your health care team better understand and treat your symptoms. It also can help you notice when your symptoms improve.
How Is It Diagnosed?
PICS is not a specific disease. Rather, it is a group of problems that people experience after being in an ICU.
To determine if you have PICS, a physical therapist will ask you questions about your ICU stay and the problems that you are experiencing. Your physical therapist can test your muscle strength, ability to walk distances and climb stairs, and your balance. They also will ask you how you are managing at home with activities such as dressing and bathing, and whether you have returned to driving and work.
Your physical therapist will ask questions to determine if you are having problems with anxiety, depression, or your thinking ability.
How Can a Physical Therapist Help?
A physical therapist can help with the physical problems related to PICS. You may receive physical therapist services in the hospital during your stay, and after your discharge at an inpatient rehabilitation center, an outpatient clinic, or in your home.
If you are having anxiety, depression, or trouble thinking, your physical therapist will refer you to other health care providers who can help you with these problems.
To help with your physical problems, your physical therapist may teach you to use tools or equipment to ease your daily tasks, such as:
- A walker or cane to help with walking.
- A raised toilet seat, or raising the height of chairs to help with standing up.
- A reaching tool to make it easier to pick things up.
Your physical therapist will work with you on specific exercises to help you get stronger, walk better, and recover from other troubles you may be having. Common types of exercises are:
- Stretching to improve flexibility.
- Resistance training, such as lifting weights or pulling on elastic bands, to improve strength.
- Aerobic exercises to improve endurance, such as walking, swimming, bicycling, or running.
- Exercises designed to improve balance.
Early on, these exercises may be harder to perform. However, doing them can help build your strength and make them less difficult. They will help your body get used to doing greater amounts of work. Not every person with PICS experiences the same level of problems. The exercises prescribed for one person may not be the same as for another person. Your physical therapist will design an exercise program specific to you to help you meet your own personal needs and goals.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat individuals in the ICU and after discharge from the hospital.
You may want to consider:
- A physical therapist with experience in treating people with PICS and physical, mental, and cognitive conditions resulting from PICS. Some physical therapists have a community-based clinic with a focus on PICS and similar conditions.
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in a specialty such as acute care, cardiopulmonary, geriatric, neurologic, orthopedic, or pediatric physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your specific condition, especially if you have spent time in a hospital ICU.
You can locate a physical therapist who has these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you’re looking for a physical therapist (or any health care provider):
- Get recommendations from family, friends, or other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists’ experience in helping people with PICS.
- During your first visit with your physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association believes that consumers should have access to information that could help them make health care decisions and also prepare them for a visit with their health care provider.
The following articles provide some of the best scientific evidence about PICS. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Smith JM, Lee AC, Zeleznik H, et al. Home and community-based physical therapist management of adults with post-intensive care syndrome. Phys Ther. 2020;100(7):1062-1073. Article Summary in PubMed.
Ohtake PJ, Lee AC, Scott JC, et al. Physical impairments associated with post-intensive care syndrome: systematic review based on the World Health Organization’s International Classification of Functioning, Disability and Health Framework. Phys Ther. 2018;98(8):631-645. Article Summary in PubMed.
Authored in 2020 by Alan C. Lee, PT, PhD; Patricia J. Ohtake, PT, PhD; James M. Smith, PT, DPT; Alecia Thiele, PT, DPT; and Hallie Zeleznik, PT, DPT on behalf of APTA’s Academy of Acute Care Physical Therapy.