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5 minutes

The authors would like to acknowledge the support of the Physiotherapy and Intensive Care Department at the Austin Hospital and St. Joseph&#8217;s Healthcare Hamilton.

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
<ol>
	<li>Identify patients appropriate for in-bed cycle ergometry, considering all contraindications and precautions (Table 1).</li>
	<li>Perform a multi-system assessment to determine the patients&#8217; neurological status, haemodynamic stability, respiratory stability, and functional ability.</li>
	<li>Use findings to determine starting mode, duration, cadence, and resistance.</li>
	<li>Screen, review, and document any preexisting pressure injuries, ensuring that it is safe to proceed with therapy.</li>
	<li>Coordinate timing of therapy with the ICU multidisciplinary team.</li>
</ol>
2. Equipment preparation
<ol>
	<li>Review all lines and attachments to the patient and secure them away from moving components of the cycle ergometer.</li>
	<li>Remove the foot of the bed if required.</li>
	<li>Position the in-bed cycle ergometer aligned with the patient&#8217;s midline.</li>
	<li>Secure the in-bed cycle ergometer to the bed and apply brakes (model dependent).</li>
</ol>
3. Patient positioning
<ol>
	<li>Maintain patient dignity (e.g., towel covering pelvic region).</li>
	<li>Position the patient semi-recumbent in supine with the head elevated and pelvis level.</li>
	<li>Place feet on pedals and secure with straps.</li>
	<li>Provide additional padding as required (e.g., using towels) to protect the skin whilst in the leg shells.</li>
	<li>Confirm alignment by completing one full pedal revolution, specifically avoiding knee hyper-extension (allow approximately 15&#176; of knee flexion) or excessive hip flexion (greater than 100&#176;).</li>
	<li>Re-check all securing mechanisms (brakes and attachments to the bed).</li>
</ol>
4. Therapy prescription
<ol>
	<li>Prescribe therapy according to options available on the model of in-bed cycle ergometer in use.</li>
	<li>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).</li>
	<li>Select duration of warm up (range 2&#8211;5 min, typically 2 min), main therapy (range 10&#8211;60 min, typically 30 min but as tolerated), and cool down (range 2&#8211;5 min, typically 2 min).</li>
	<li>Select target rate per minute (range 5&#8211;30 RPM, minimum 5 RPM).</li>
	<li>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&#8217;s tolerance.</li>
</ol>
5. Patient monitoring during therapy
<ol>
	<li>Commence therapy once therapy prescription has been completed and checked.</li>
	<li>Monitor observations and vital signs for breaches of stopping criteria throughout the session.</li>
	<li>Monitor lines and attachments.</li>
	<li>Monitor patient interaction.</li>
	<li>Adjust therapy according to patient interaction and/or any changes in observations and vital signs.</li>
</ol>
6. Progression criteria
<ol>
	<li>Encourage the patient using verbal cues.</li>
	<li>Evaluate patient participation in therapy.</li>
	<li>Progress one variable at a time if able (duration first, then resistance).
	<ol>
		<li>Increase rate if participation is limited. Decrease rate if patient participation is increasing.</li>
		<li>Adjust duration of session based on tolerance.</li>
	</ol>
	</li>
</ol>
7. Termination criteria
<ol>
	<li>Immediately cease activity if stopping criteria are met (Table 2). Remove the patient&#8217;s feet from pedals. Reassess vital signs immediately and notify the ICU team if instability persists.</li>
	<li>Otherwise terminate session once desired duration has been reached or the patient elects to cease the session.</li>
	<li>Stop therapy and ensure the in-bed cycle ergometer has ceased movement.</li>
	<li>Remove feet from pedals.</li>
	<li>Remove all securing devices.</li>
	<li>Release brakes.</li>
	<li>Remove the in-bed cycle ergometer.</li>
	<li>Clean the cycle ergometer in accordance with local policy for shared patient equipment.</li>
</ol>
8. Postsession procedures
<ol>
	<li>Review the patient for the presence of any new pressure or shear injuries. If present, document and inform the team.</li>
	<li>Reassess observations and vital signs.</li>
	<li>Evaluate patient participation in therapy. Adjust therapy prescription for future sessions.</li>
	<li>Document session details in the medical record.</li>
	<li>Communicate outcomes with the multidisciplinary team.</li>
</ol>

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.

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 ...

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&#8217;s condition and level of participation20. First, the intervention may be delivered passively, where the motor drives the pedals, which move the patients&#8217; 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&#160;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&#8212;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).&#160; 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.

<table><tbody><tr><td>MOTOMed Letto2</td><td>RECK-Technik GmbH &amp;amp; Co. KG</td><td></td><td>info@motomed.com</td></tr><tr><td>RT300 Supine</td><td>Restorative Therapies, Baltimore, MD</td><td></td><td>&amp;nbsp;https://restorative-therapies.com</td></tr></tbody></table>

implementing in-bed cycle ergometry for mechanically ventilated patients using the rehabilitation treatment specification system

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

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.

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...

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.

In-bed cycle ergometry is a safe, feasible, and reliable method of providing in-bed physical rehabilitation for patients with critical illness in the ...

implementing-bed-cycle-ergometry-for-mechanically-ventilated-patients

Research

JoVE Journal

Medicine

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Evaluation of Respiratory Muscle Activation Using Respiratory Motor Control Assessment (RMCA) in Individuals with Chronic Spinal Cord Injury

Spinal cord injury is a traumatic medical condition that may result in elevated risks of chronic secondary metabolic disorders. Here, we presented a protocol using surface neuromuscular electrical stimulation-resistance training in conjunction with functional electrical stimulation-lower extremities cycling as a strategy to ameliorate several of these medical problems.

Paradigms of Lower Extremity Electrical Stimulation Training After Spinal Cord Injury

This curriculum outlines how to execute a simulation-based boot camp to teach providers how to manage mechanically ventilated patients.

Mechanical Ventilation Boot Camp Curriculum

This protocol integrated near-infrared spectroscopy into conventional cardiopulmonary exercise testing to identify the involvement of the cerebral hemodynamic response in exercise intolerance in patients with heart failure.

Integration of Brain Tissue Saturation Monitoring in Cardiopulmonary Exercise Testing in Patients with Heart Failure

Electrical Impedance Tomography is a non-invasive, radiation-free, real-time pulmonary ventilation monitoring tool. By measuring impedance changes in the thorax, it can visualize the distribution of air on a breath-by-breath basis. Initially intended for ventilation monitoring, electrical impedance tomography can also measure perfusion via intravenous injection of a saline solution.

Monitoring Lung Function with Electrical Impedance Tomography in the Intensive Care Unit

The efficacy of combining exoskeleton-assisted, body weight-supported treadmill training with game-based virtual reality on dual-task capability in stroke survivors has yet to be studied. Therefore, this rehabilitation program aims to investigate the potential functions and advantages of this combination in enhancing walking capability during stroke recovery.

A Rehabilitation Program of Exoskeleton-assisted Body Weight-Supported Treadmill Training with Non-immersive Virtual Reality for Stroke Patients

This protocol aims to evaluate the clinical efficacy and patient comfort of using bedside lower limb rehabilitation robots for post-stroke hemiplegia rehabilitation, comparing outcomes with those of traditional manual therapy through randomized controlled trials.

Application of Bedside Lower Extremity Rehabilitation Robots in Stroke Rehabilitation: A Randomized Controlled Trial

Survivors of acute respiratory distress syndrome (ARDS) and critical illness frequently develop long-lasting muscle weakness. Manual muscle testing (MMT) is a standardized clinical examination commonly used to measure strength of peripheral skeletal muscle groups.  This video demonstrates MMT using the 6-point  Medical Research Council scale.

Manual Muscle Testing:  A Method of Measuring Extremity Muscle Strength Applied to Critically Ill Patients 

Loss of peritoneal integrity provides a new paradigm to understand and treat chronic pelvic pain in women with mild forms of endometriosis and can be easily detected using intraoperative instillation of dye at the time of laparoscopy.

Intraoperative Detection of Subtle Endometriosis: A Novel Paradigm for Detection and Treatment of Pelvic Pain Associated with the Loss of Peritoneal Integrity

This protocol describes a procedure to track the evolution of mesial network measures in temporal lobe epilepsy (TLE) patients. It is based on the combination of intracranial recordings with a novel numerical technique for data analysis. Specifically, we present a protocol for network analyses of foramen ovale recordings.

Network Analysis of Foramen Ovale Electrode Recordings in Drug-resistant Temporal Lobe Epilepsy Patients

119 Views.  Austin Health. 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.

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

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