By Deborah Borfitz 

July 30, 2026 | The findings of more than 150 randomized controlled trials provide ample evidence that early mobilization of patients with acute respiratory failure (ARF) in the intensive care unit (ICU) is both safe and beneficial. Surprisingly, also giving them extra protein—a strategy used successfully with frail and elderly patients—doesn’t appear to have any additive benefit, according to Dale Needham, M.D., Ph.D., professor of pulmonary and critical care medicine and physical medicine and rehabilitation at the Johns Hopkins University School of Medicine.    

Needham and Stephanie Hiser, Ph.D., a physical therapist at Johns Hopkins Hospital, were part of the nearly decade-long Nutrition and Exercise in Critical Illness (NEXIS) trial looking at whether added protein nutritional intake could improve physical recovery for critically ill ARF patients (American Journal of Respiratory and Critical Care Medicine, DOI: 10.1093/ajrccm/aamag287). 

Notably, the study was conducted across nine U.S. academic medical centers unlikely to be representative of hospitals throughout the U.S., says Needham. That meant the control group received usual care rehabilitation of greater frequency than typical ICUs in the U.S., helping to explain why even the exercise portion of the intervention—in this case, in-bed cycling—did not show improved patient outcomes.  

Early rehab needs to replace the traditional approach of over-sedating patients, which unfortunately is still the standard practice in many hospital ICUs, says Hiser. “I always think about exercise and rehab like a drug ... [with an] optimal therapeutic window” where the dose is neither too low to provide improvement nor too high and causes adverse side effects. 

Next steps for the research team, once funding is secured, are to determine the best doses to give patients, says Needham. When rehabilitation therapists are scarce resources in the ICU, as they typically are, more patients are helped by knowing the threshold where more therapy stops speeding up recovery.  

Various types of evidence-based rehabilitation interventions are provided in the ICU, often by physical therapists but also occupational therapists and speech-language pathologists as well as nurses and doctors, says Needham. There have been no large, well-designed randomized trials supporting a pharmaceutical approach to reducing muscle weakness in critically ill patients. 

ARF is one of the top and most common admitting diagnoses in the ICU, he notes. Among patients with acute respiratory distress syndrome, a severe type of ARF, post-ICU muscle weakness was independently associated with worse five-year survival in a 2017 study (Critical Care Medicine, DOI: 10.1097/CCM.0000000000002208)  

This is one of numerous studies showing a strong link between physical function and mortality, says Hiser. “We know when patients leave the hospital and they’re not able to move around as easily, it’s putting them at risk for other sequelae such as continued infections, pneumonia, [and] bedsores ... that could unfortunately lead them back to the hospital.” 

In a financial analysis of early rehabilitation conducted by Needham and his colleagues back in 2013, the affiliated savings was pegged at close to one million in an example scenario at a hospital with 900 annual admissions (Critical Care Medicine, DOI: 10.1097/CCM.0b013e3182711de2). The news made the front page of The New York Times and followed the launch of the annual Johns Hopkins Critical Care Rehabilitation Conference attracting people from around the world to learn about its multidisciplinary approach to care. 

Unique Patient Population 

Needham has been involved in shaping the international clinical practice guidelines in ICU rehabilitation being collaboratively developed by the American Thoracic Society and European Respiratory Society, which are expected to be made publicly available in another few months, he says. The most current clinical practice guideline was issued by the Society of Critical Care Medicine last year, an update to its original 2018 advice that recommended enhanced mobilization over usual rehabilitation (Critical Care Medicine, DOI: OI: 10.1097/CCM.0000000000006574). Many countries, including Japan and Korea, also have their own guidelines. 

While a large body of evidence ties early mobilization to ICU recovery milestones, rehabilitation is a broad term that includes everything from in-bed rolling and range of motion exercises to treadmill training and hydrotherapy, including people on life support, says Needham. “Where the evidence is much more limited is the combination of protein and exercise while patients are in the ICU,” making it the number one research priority in the critical care field. The dual approach has been demonstrated to improve muscle strength among elderly and frail individuals. 

Many people in the ICU are older and, even if they come in younger and strong, often leave looking frail and unable to walk, Needham continues. “That muscle weakness can last for months or years after they’ve been critically ill,” and this includes former weightlifters who once bench-pressed hundreds of pounds but later struggle to lift half that amount. 

“But of course the people who are most vulnerable aren’t the weightlifters who are going to make it back to work,” he says. “It’s older people who become so weak that they can’t lift their feet to get up two steps into their house, and then they may not go home because that weakness is going to prevent them from resuming their regular activities.”