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Method Article

Implementing In-bed Cycle Ergometry for Mechanically Ventilated Patients using the Rehabilitation Treatment Specification System

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DOI:

10.3791/70304

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July 7th, 2026

 ,  ,  ,  ,  , 
1Department of Physiotherapy, Austin Health, 2Department of Physiotherapy, The University of Melbourne, 3Institute for Breathing and Sleep, 4School of Rehabilitation Science, McMaster University, 5Niagara Knowledge Institute, 6Department of Physiotherapy, Ipswich Hospital, West Moreton Health, 7Research Institute of St. Joe's Hamilton

In This Article

Summary

Protocols for the delivery of in-bed leg cycle ergometry to critically ill patients in the intensive care unit are presented according to the Rehabilitation Treatment Specification System to promote standardization of procedures, ensure patient safety, and support reproducibility across clinical and research settings.

Abstract

In-bed cycle ergometry is a safe, feasible, and reliable method of providing in-bed physical rehabilitation for patients with critical illness in the intensive care unit. It is a complex intervention that requires specific clinical decision-making skills to identify suitable patients, close coordination with the team to deliver the intervention, and ongoing evaluation to guide treatment progression. Protocols for the delivery of in-bed cycle ergometry are presented according to the Rehabilitation Treatment Specification System. Specifically, the components of in-bed leg cycle ergometry are described, including preparation, equipment, therapist actions (instructions and feedback), progression considerations, and clinical decision-making.

Patient selection for in-bed cycle ergometry in the intensive care unit should prioritize physiological stability, with safety criteria for starting and stopping, and defined inclusion and exclusion criteria to support standardized and reproducible delivery. The patient should be in the semi-recumbent position, with the in-bed cycle ergometer secured at the foot of the bed and neutral lower limb alignment maintained. Dosing and progression should consider active or passive modes, frequency, duration, cadence, and resistance. Patient monitoring should include clearly specified physiological and tolerance thresholds, with increases applied systematically. Documentation of treatments following the Rehabilitation Treatment Specification System supports clinical decision-making, standardization, and reproducibility.

Introduction

Physical disability is often a severe and long-lasting consequence of critical illness1,2. Advances in intensive care medicine have improved survival rates over the last 30 years3. However, there is emerging recognition of the impact of physical impairments experienced by survivors following discharge from the intensive care unit (ICU)4. Long-term physical impairments originate from ICU-acquired weakness (ICU-AW), a global, symmetrical neuromuscular weakness related to the ICU admission alone5. Factors contributing to the development of ICU-AW include prolonged bed rest and systemic inflammation, resulting in a net catabolic state, which leads to accelerated muscle atrophy6,7. Losses of up to 20% of skeletal muscle mass have been reported in the first ten days of ICU admission. Further, the development of ICU-AW increases the risk of death, prolonged mechanical ventilation and protracted admissions in ICU and hospital8.

Rehabilitation of patients with critical illness commences in the ICU environment and typically includes exercise therapy and progressive functional mobility9. When rehabilitation begins in the ICU, it is associated with improved physical function at hospital discharge and reduced length of stay in both the ICU and hospital settings10,11. However, early initiation of rehabilitation is conditional on haemodynamic and metabolic stability12. In-bed cycle ergometry has emerged as a novel approach of providing in-bed exercise to patients with critical illness13,14. In-bed cycle ergometry may be applied to either the upper or lower limbs15,16. Importantly, in-bed cycle ergometry is safe17,18, feasible and an acceptable therapy for patients with critical illness19, which may improve physical function at ICU discharge and beyond15.

However, in-bed cycle ergometry is a complex rehabilitation intervention that lacks published guidance on practical implementation, particularly for patients undergoing mechanical ventilation in the ICU. In-bed cycle ergometry can be delivered in different modes depending on the patient’s condition and level of participation20. First, the intervention may be delivered passively, where the motor drives the pedals, which move the patients’ legs without voluntary effort19. Second, it may be performed actively, where the patient contributes to the movement of the pedals with or without assistance from the motor19. Third, in the setting of active participation, resistance may be added to provide a greater training stimulus in those able to tolerate this19.

Therefore, we aim to provide a structured, reproducible protocol for in-bed leg-cycle ergometry of the lower limbs21. Specifically, we will outline the processes for the preparation of the patient, equipment, therapist actions, including instructions and feedback, progression considerations, and clinical decision-making for in-bed cycle ergometry. This protocol is based on evidence from a recently published randomized controlled trial18 and systematic reviews and meta-analyses15,22.

Introduction to the Rehabilitation Treatment Specification System
The Rehabilitation Treatment Specification System (RTSS) was developed by a multidisciplinary team of rehabilitation specialists to provide a structured and rigorous framework for defining, classifying, and measuring rehabilitation treatments21. Its development was prompted by a lack of detailed description of rehabilitation treatment methods in both research23 and clinical practice24. Reporting guidelines describe study conduct (e.g., CONSORT25), individual components of interventions (e.g., TIDier; template for intervention description and intervention26 and CERT; Consensus on Exercise Reporting Template27), and frameworks like the International Classification of Function (ICF28), which classify overall goals of treatment (e.g., walking). However, these systems focus on who and what of rehabilitation. Rehabilitation treatments are frequently described solely in terms of service duration (e.g., minutes of physiotherapy intervention) or the specific problems they aim to treat (e.g., mobility training), or the care setting (e.g., ICU).

What existing frameworks do not describe is the how of rehabilitation—what the clinician does or provides to a patient in a therapy session to achieve a specific change in patient function. The RTSS is intended to organize treatments according to the change in function that the clinician and treatment recipient hope to achieve in a session, which is the target of intervention; the ingredients (what the clinician provides or does that is hypothesized to effect that change in function); and the mechanisms of action by which the clinician hypothesizes the ingredients have their effects29. Treatment targets must be measurable, and are categorized into three groups: Organ Functions, Skills and Habits, and Representations (changes in thinking or feeling)23. Changes in organ function can be achieved passively, for example, through limb passive range of motion with the treatment target of maintaining existing joint range of motion and preventing contractures; or actively, through limb active range of motion with the application of graded resistance, with the treatment target of increasing muscle strength. For both Skills and Habits and Representation targets, the treatment recipient is an active participant.

The RTSS has been applied to physical rehabilitation of children and adults30,31,32,33,34,35,36,37, and there are guidelines for embedding it into standard clinical care38 (Figure 1).  Here, we will apply the RTSS to in-bed cycle ergometry with critically ill patients, describing the intervention according to its targets, hypothesized mechanisms of action, and ingredients.

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Protocol

All procedures included within this protocol reflect primary studies that adhered to local institutional ethical standards and guidelines. No specific ethical approval was required for this protocol article.

1. Patient selection and presession assessment

  1. Identify patients appropriate for in-bed cycle ergometry, considering all contraindications and precautions (Table 1).
  2. Perform a multi-system assessment to determine the patients’ neurological status, haemodynamic stability, respiratory stability, and functional ability.
  3. Use findings to determine starting mode, duration, cadence, and resistance.
  4. Screen, review, and document any preexisting pressure injuries, ensuring that it is safe to proceed with therapy.
  5. Coordinate timing of therapy with the ICU multidisciplinary team.

2. Equipment preparation

  1. Review all lines and attachments to the patient and secure them away from moving components of the cycle ergometer.
  2. Remove the foot of the bed if required.
  3. Position the in-bed cycle ergometer aligned with the patient’s midline.
  4. Secure the in-bed cycle ergometer to the bed and apply brakes (model dependent).

3. Patient positioning

  1. Maintain patient dignity (e.g., towel covering pelvic region).
  2. Position the patient semi-recumbent in supine with the head elevated and pelvis level.
  3. Place feet on pedals and secure with straps.
  4. Provide additional padding as required (e.g., using towels) to protect the skin whilst in the leg shells.
  5. Confirm alignment by completing one full pedal revolution, specifically avoiding knee hyper-extension (allow approximately 15° of knee flexion) or excessive hip flexion (greater than 100°).
  6. Re-check all securing mechanisms (brakes and attachments to the bed).

4. Therapy prescription

  1. Prescribe therapy according to options available on the model of in-bed cycle ergometer in use.
  2. Select initial therapy mode from: Passive, Active-assisted/Active, or Resisted (Passive if patient unable to participate, Active if able to participate, Resisted if easily able to participate).
  3. Select duration of warm up (range 2–5 min, typically 2 min), main therapy (range 10–60 min, typically 30 min but as tolerated), and cool down (range 2–5 min, typically 2 min).
  4. Select target rate per minute (range 5–30 RPM, minimum 5 RPM).
  5. Adjust the resistance for patients by beginning with a low resistance of less than 0.6 Nm and increasing in increments of 1 to 5 watts Nm in response to the patient’s tolerance.

5. Patient monitoring during therapy

  1. Commence therapy once therapy prescription has been completed and checked.
  2. Monitor observations and vital signs for breaches of stopping criteria throughout the session.
  3. Monitor lines and attachments.
  4. Monitor patient interaction.
  5. Adjust therapy according to patient interaction and/or any changes in observations and vital signs.

6. Progression criteria

  1. Encourage the patient using verbal cues.
  2. Evaluate patient participation in therapy.
  3. Progress one variable at a time if able (duration first, then resistance).
    1. Increase rate if participation is limited. Decrease rate if patient participation is increasing.
    2. Adjust duration of session based on tolerance.

7. Termination criteria

  1. Immediately cease activity if stopping criteria are met (Table 2). Remove the patient’s feet from pedals. Reassess vital signs immediately and notify the ICU team if instability persists.
  2. Otherwise terminate session once desired duration has been reached or the patient elects to cease the session.
  3. Stop therapy and ensure the in-bed cycle ergometer has ceased movement.
  4. Remove feet from pedals.
  5. Remove all securing devices.
  6. Release brakes.
  7. Remove the in-bed cycle ergometer.
  8. Clean the cycle ergometer in accordance with local policy for shared patient equipment.

8. Postsession procedures

  1. Review the patient for the presence of any new pressure or shear injuries. If present, document and inform the team.
  2. Reassess observations and vital signs.
  3. Evaluate patient participation in therapy. Adjust therapy prescription for future sessions.
  4. Document session details in the medical record.
  5. Communicate outcomes with the multidisciplinary team.

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Results

Successful implementation of this protocol of in-bed cycle ergometry will result in a completed physical rehabilitation session of in-bed cycle ergometry that is safe and without adverse events. Typical sessions may commence passively whilst a patient is sedated, unconscious, and unable to participate. The cadence will commence slowly (e.g., 5 RPM) and increase up to 30 RPM, or the patient’s self-selected pace. The duration of sessions will increase over time up to a total of 60 minutes as tolerance increases. Passive se...

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Discussion

In-bed cycle ergometry is a safe, feasible, and reliable therapy option for patients mechanically ventilated in the ICU that improves physical function by ICU and hospital discharge15.

Applying the RTSS to in-bed cycle ergometry
Figure 2 summarizes examples of targets, mechanisms of action, ingredients, and potential measures for in-bed cycle ergometry. We developed our approach to implementing in-bed cycle ergometry ...

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Disclosures

Michelle Kho received the loan of 4-four RT300 supine cycle ergometers from Restorative Therapies (Baltimore, MD) for the CYCLE RCT. Restorative Therapies had no input in the content of this article or the decision to submit for publication.

Acknowledgements

The authors would like to acknowledge the support of the Physiotherapy and Intensive Care Department at the Austin Hospital and St. Joseph’s Healthcare Hamilton.

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Materials

List of materials used in this article
NameCompanyCatalog NumberComments
MOTOMed Letto2RECK-Technik GmbH & Co. KGinfo@motomed.com
RT300 SupineRestorative Therapies, Baltimore, MD https://restorative-therapies.com

References

  1. Hodgson, C. L., et al. The impact of disability in survivors of critical illness. Intensive Care Med. 43 (7), 992-1001 (2017).
  2. Needham, D. M., Feldman, D. R., Kho, M. E. The functional costs of ICU survivorship. Am J Respir Crit Care Med. 183 (8), 962-964 (2011).
  3. Pilowsky, J. K., et al. Mortality trends across key diagnostic groups in Australian and New Zealand ICUs over the past 30 years. Crit Care Med. 53 (11), e2124-e2133 (2025).
  4. Herridge, M. S., et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med. 364 (14), 1293-1304 (2011).
  5. Latronico, N., Rasulo, F. A., Eikermann, M., Piva, S. Illness weakness, polyneuropathy and myopathy: diagnosis, treatment, and long-term outcomes. Crit Care. 27 (1), 439(2023).
  6. Chen, J., Huang, M. Intensive care unit-acquired weakness: recent insights. J Intensive Med. 4 (1), 73-80 (2024).
  7. Rollinson, T. C., et al. Ultrasound-derived rates of muscle wasting in the intensive care unit and in the post-intensive care ward for patients with critical illness: post hoc analysis of an international, multicentre randomised controlled trial of early rehabilitation. Aust Crit Care. 37 (6), 873-881 (2024).
  8. Hermans, G., et al. Acute outcomes and 1-year mortality of intensive care unit-acquired weakness: a cohort study and propensity-matched analysis. Am J Respir Crit Care Med. 190 (4), 410-420 (2014).
  9. Reid, J. C., et al. Physical rehabilitation interventions in the intensive care unit: a scoping review of 117 studies. J Intensive Care. 6 (1), (2018).
  10. Tipping, C. J., et al. The effects of active mobilisation and rehabilitation in ICU on mortality and function: a systematic review. Intensive Care Med. 43 (2), 171-183 (2017).
  11. Wang, Y. T., Lang, J. K., Haines, K. J., Skinner, E. H., Haines, T. P. Physical rehabilitation in the ICU: a systematic review and meta-analysis. Crit Care Med. 50 (3), 375-388 (2022).
  12. Nydahl, P., et al. Safety of patient mobilization and rehabilitation in the intensive care unit: systematic review with meta-analysis. Ann Am Thorac Soc. 14 (5), 766-777 (2017).
  13. Burtin, C., et al. Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med. 37 (9), 2499-2505 (2009).
  14. Kho, M. E., et al. Multicentre pilot randomised clinical trial of early in-bed cycle ergometry with ventilated patients. BMJ Open Respir Res. 6 (1), e000383(2019).
  15. O’Grady, H. K., et al. Leg cycle ergometry in critically ill patients: an updated systematic review and meta-analysis. NEJM Evid. 3 (12), EVIDoa2400194(2024).
  16. Vanderlelie, L., et al. Arm cycle ergometry in critically ill patients: a systematic review. Aust Crit Care. 37 (6), 985-993 (2024).
  17. Takaoka, A., Utgikar, R., Rochwerg, B., Cook, D. J., Kho, M. E. The efficacy and safety of in–intensive care unit leg-cycle ergometry in critically ill adults: a systematic review and meta-analysis. Ann Am Thorac Soc. 17 (10), 1289-1307 (2020).
  18. Kho, M. E., et al. Early in-bed cycle ergometry in mechanically ventilated patients. NEJM Evid. 3 (7), EVIDoa2400137(2024).
  19. Nickels, M. R., Aitken, L. M., Barnett, A. G., Walsham, J., McPhail, S. M. Acceptability, safety, and feasibility of in-bed cycling with critically ill patients. Aust Crit Care. 33 (3), 236-243 (2020).
  20. Nickels, M. R., et al. Effect of in-bed cycling on acute muscle wasting in critically ill adults: a randomised clinical trial. J Crit Care. 59, 86-93 (2020).
  21. Hart, T., et al. A theory-driven system for the specification of rehabilitation treatments. Arch Phys Med Rehabil. 100 (1), 172-180 (2019).
  22. Pazo-Palacios, R., et al. Effects of in-bed cycling in critically ill adults: a systematic review and meta-analysis of randomised clinical trials. Ann Phys Rehabil Med. 68 (5), 101953(2025).
  23. Van Stan, J. H., et al. The rehabilitation treatment specification system: implications for improvements in research design, reporting, replication, and synthesis. Arch Phys Med Rehabil. 100 (1), 146-155 (2019).
  24. Zanca, J. M., et al. Advancing rehabilitation practice through improved specification of interventions. Arch Phys Med Rehabil. 100 (1), 164-171 (2019).
  25. Boutron, I., Moher, D., Altman, D. G., Schulz, K. F., Ravaud, P. Extending the CONSORT statement to randomized trials of nonpharmacologic treatment: explanation and elaboration. Ann Intern Med. 148 (4), 295-309 (2008).
  26. Hoffmann, T. C., et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 348, g1687(2014).
  27. Slade, S. C., Dionne, C. E., Underwood, M., Buchbinder, R. Consensus on exercise reporting template (CERT): explanation and elaboration statement. Br J Sports Med. 50 (23), 1428(2016).
  28. Madden, R., Sykes, C., Bedirhan Ustun, T. World Health Organization Family of International Classifications: definition, scope and purpose. , http://www.who.int/classifications/en/FamilyDocument2007.pdf (2007).
  29. Hart, T., et al. Manual of rehabilitation treatment specification. , http://mrri.org/innovations/manual-for-rehabilitation-treatment-specification (2018).
  30. Corro, N. Pediatric constraint-induced movement therapy as designed using rehabilitation treatment specification system. Arch Phys Med Rehabil. 106 (4), e110-e111 (2025).
  31. de Sousa Junior, R. R., et al. Modified sports interventions for children and adolescents with disabilities: a scoping review. Dev Med Child Neurol. 66 (11), 1432-1445 (2024).
  32. Gibson, J., Sampford, J., Myers-Ingram, R., Jones, G. D. Embedding the rehabilitation treatment specification system (RTSS) into clinical practice: an evaluation of a pilot teaching programme. BMC Med Educ. 23 (1), 85(2023).
  33. Lambe, K., et al. Effect of inpatient rehabilitation treatment ingredients on functioning, quality of life, length of stay, discharge destination, and mortality among older adults with unplanned admission: an overview review. BMC Geriatr. 22 (1), 501(2022).
  34. Lyons, K. D., et al. Using the rehabilitation treatment specification system to describe experimental and control arms of a clinical trial for breast cancer survivors. Rehabil Oncol. 42 (4), 181-197 (2024).
  35. Halsey, A. R., Kruk, V., Wengerd, L. Using the rehabilitation treatment specification system to characterize OT interventions for stroke-related upper extremity hemiparesis. Am J Occup Ther. 79 (Suppl 2), 7911500321p(2025).
  36. Sampford, J., Jones, G., Myers-Ingram, R., Gibson, J., O’Keeffe, M. Not another rehabilitation ‘black box’: effective outcomes when a physiotherapy-led weight management intervention is specified. Physiotherapy. 123, e95-e96 (2024).
  37. Sheehan, K. J., et al. Structured tailored rehabilitation after hip fragility fracture: the ‘Stratify’ feasibility and pilot randomised controlled trial protocol. PLoS One. 19 (12), e0306870(2024).
  38. Wolfberg, J., Whyte, J., Van Stan, J. Applying/adapting the rehabilitation treatment specification system for documenting standard clinical care. Arch Phys Med Rehabil. 103 (12), e121(2022).
  39. Burton, D. A., Stokes, K., Hall, G. M. Physiological effects of exercise. Continuing Education in Anaesthesia Critical Care Pain. 4 (6), 185-188 (2004).
  40. Van Stan, J. H., et al. Voice therapy according to the rehabilitation treatment specification system: expert consensus ingredients and targets. Am J Speech Lang Pathol. 30 (5), 2169-2201 (2021).
  41. Kress, J. P., Hall, J. B. ICU-acquired weakness and recovery from critical illness. N Engl J Med. 370 (17), 1626-1635 (2014).
  42. Berney, S. C., Rose, J. W., Bernhardt, J., Denehy, L. Prospective observation of physical activity in critically ill patients who were intubated for more than 48 hours. J Crit Care. 30 (4), 658-663 (2015).
  43. Rollinson, T. C., Connolly, B., Berlowitz, D. J., Berney, S. Physical activity of patients with critical illness undergoing rehabilitation in intensive care and on the acute ward: an observational cohort study. Aust Crit Care. 35 (4), 362-368 (2021).
  44. Kho, M. E., et al. TryCYCLE: a prospective study of the safety and feasibility of early in-bed cycling in mechanically ventilated patients. PLoS One. 11 (12), e0167561(2016).
  45. Watanabe, K., et al. Neuromuscular activation pattern of lower extremity muscles during pedaling in cyclists with single amputation of leg and with two legs: a case study. BMC Res Notes. 13 (1), 299(2020).
  46. Dietz, V., Harkema, S. J. Locomotor activity in spinal cord-injured persons. J Appl Physiol. 96 (5), 1954-1960 (2004).
  47. Hermans, G., Van den Berghe, G. Clinical review: intensive care unit acquired weakness. Crit Care. 19 (1), 274(2015).
  48. Jameson, T. S. O., et al. Inflammation and altered metabolism impede efficacy of functional electrical stimulation in critically ill patients. Crit Care. 27 (1), 428(2023).
  49. Berney, S., et al. Functional electrical stimulation in-bed cycle ergometry in mechanically ventilated patients: a multicentre randomised controlled trial. Thorax. 76 (7), 656-663 (2021).
  50. Parry, S. M., et al. Early rehabilitation in critical care (eRiCC): functional electrical stimulation with cycling protocol for a randomised controlled trial. BMJ Open. 2 (5), e001891(2012).
  51. Nickels, M. R., Aitken, L. M., Walsham, J., Barnett, A. G., McPhail, S. M. Critical care cycling study (CYCLIST) trial protocol: a randomised controlled trial of usual care plus additional in-bed cycling sessions versus usual care in the critically ill. BMJ Open. 7 (10), e017393(2017).
  52. Kho, M. E., et al. Critical care cycling to improve lower extremity strength (CYCLE): protocol for an international, multicentre randomised clinical trial of early in-bed cycling for mechanically ventilated patients. BMJ Open. 13 (6), e075685(2023).
  53. Paton, M., et al. Association of active mobilisation variables with adverse events and mortality in patients requiring mechanical ventilation in the intensive care unit: a systematic review and meta-analysis. Lancet Respir Med. 12 (5), 386-398 (2024).
  54. Farley, C., et al. Treatment fidelity in 94 randomized controlled trials of physical rehabilitation in the ICU: a scoping review. Crit Care Med. 52 (5), 717-728 (2024).
  55. Wright, S. E., et al. Intensive versus standard physical rehabilitation therapy in the critically ill (EPICC): a multicentre, parallel-group, randomised controlled trial. Thorax. 73 (3), 213-221 (2018).
  56. Connolly, B. A., et al. PRACTICE: development of a core outcome set for trials of physical rehabilitation in critical illness. Ann Am Thorac Soc. 21 (12), 1742-1750 (2024).
  57. Jawed, Y. T., et al. Feasibility of a virtual reality intervention in the intensive care unit. Heart Lung. 50 (6), 748-753 (2021).
  58. Ong, T. L., et al. Improving the intensive care patient experience with virtual reality: a feasibility study. Crit Care Explor. 2 (6), e0122(2020).
  59. He, Y., et al. Effects of virtual reality technology on early mobility in critically ill adult patients: a systematic review and meta-analysis. Front Neurol. 15, 1469079(2024).

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Intensive Care UnitPhysical RehabilitationPatient SelectionClinical Decision-MakingLeg Cycle ErgometryPatient MonitoringTreatment Progression
Implementing In-bed Cycle Ergometry for Mechanically Ventilated Patients using the Rehabilitation Treatment Specification System
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