Description of physical rehabilitation in intensive care units in Argentina: usual practice and during the COVID-19 pandemic. Online survey

Objective To describe the usual practice of mobility therapy in the adult intensive care unit for patients with and without COVID-19. Methods Online survey in which physical therapists working in an adult intensive care unit in Argentina participated. Sixteen multiple-choice or single-response questions grouped into three sections were asked. The first section addressed personal, professional and work environment data. The second section presented questions regarding usual care, and the third focused on practices under COVID-19 pandemic conditions. Results Of 351 physical therapists, 76.1% answer that they were exclusively responsible for patient mobility. The highest motor-based goal varied according to four patient scenarios: Mechanically ventilated patients, patients weaned from mechanical ventilation, patients who had never required mechanical ventilation, and patients with COVID-19 under mechanical ventilation. In the first and last scenarios, the highest goal was to optimize muscle strength, while for the other two, it was to perform activities of daily living. Finally, the greatest limitation in working with patients with COVID-19 was respiratory and/or contact isolation. Conclusion Physical therapists in Argentina reported being responsible for the mobility of patients in the intensive care unit. The highest motor-based therapeutic goals for four classic scenarios in the closed area were limited by the need for mechanical ventilation. The greatest limitation when mobilizing patients with COVID-19 was respiratory and contact isolation.

strength and physical function and decreasing the number of days of MV, the length of stay in the ICU and hospital, mortality rates and the incidence of delirium. (10)(11)(12) However, early mobilization faces barriers and limitations related to the staff care, medical supplies, and the respiratory, cardiovascular and/or neurological conditions of the patients. (10,13) In the context of the COVID-19 pandemic and given the need to implement respiratory and contact isolation (14) along with more frequent prone positioning (15) as a strategy for refractory hypoxemia, (16) we believe that both the quality and quantity of mobility intervention could be affected in ways that undermine the previously mentioned benefits.
Currently, early mobilization is guided by the practices of individual institutions, and consensus regarding both terminology and way of implementation is lacking. In this regard, we found no information in the literature regarding usual practices related to early mobilization in Argentina or whether the pandemic has affected its implementation in the ICU.
For this reason, the objective of the present survey was to describe the usual practice of mobility therapy for patients with and without COVID-19 in Argentinian adult ICUs.

METHODS
A cross-sectional observational study was conducted online from June 1 to June 30, 2020. A bibliographic search was conducted in the MEDLINE database using the terms "early mobilization", "critical care", "physical therapy", "rehabilitation" and "survey". Relevant articles in English or Spanish were identified from the obtained results, and those that included information relevant to the rehabilitation process in intensive care were submitted to a full-text review. In turn, bibliographic citations were consulted to expand the possible selection of relevant information. In addition, a semistructured interview of three seniors physical therapists who were specialists in intensive care was conducted to determine variables and relevant questions to include.
Subsequently, the information was summarized, and a first version of the survey was prepared and reviewed by the authors of the study and one physical therapist with more than 10 years of experience in critical care. From this, the second version, consisting of 26 items, was agreed upon. This version was evaluated in a pilot test of 15 subjects who completed the survey and reported on the clarity of the statements along with the time needed to complete it, which varied between 3 and 5 minutes.
After the first draft was completed, the final version consisted of 16 multiple-choice or single-response questions. They were grouped into three sections. The first section pertained to the respondents' personal, professional or work environment data. The second section asked about the participants' usual actions in terms of limitations or barriers, maximum treatment goals in different scenarios and measurement tools used to assess changes in patients' physical condition. The third section addressed mobility therapy in the context of the COVID-19 pandemic (Annex 1). The confidentiality of all information obtained was strictly maintained by the researchers; the participants' data were protected by the Argentine Personal Data Protection Law No. 25,326 (Habeas data law). All data were collected through a virtual platform (Google forms®) and subsequently anonymized, and access was restricted to authorized personnel for the purposes of the study only to ensure the confidentiality of the information.
Physical therapists working in adult ICUs in Argentina were included. A convenience sample was obtained from a database developed by the study authors. Through nonprobabilistic sampling, physical therapists were invited to participate via email and social networks (WhatsApp®, Twitter® and Facebook®). No survey was eliminated later because only complete surveys were accepted. The link was shared by three of the researchers, and in cases where no response was obtained via email, it was re-forwarded every week up to a maximum of three times. The present work was approved by the Teaching and Research Committee of the Sanatorio Anchorena San Martín.

Statistical analysis
Categorical variables are presented as absolute numbers and percentages. Continuous variables with a normal distribution are presented as the mean and standard deviation (SD). For the analysis of the data, the statistical program SPSS version 24 (IBM Corp, Armonk, NY, USA) was used.

RESULTS
From June 1 to 30, 2020, 351 physical therapists in Argentina answered to the survey. Their median age was 34 (IQR 31 -40) years. A total of 45.3% worked in the Autonomous City of Buenos Aires (CABA), 37.6% worked in the province of Buenos Aires, and the remaining proportion was distributed throughout 19 Argentine provinces ( Table 1). The public sphere presented the greatest care burden (57.3%). Among the physical therapists, 76.1% reported that patient mobility is exclusively their responsibility. A total of 23.6% of the centers had mobilization protocols in place in the ICU. In the second section, concerning the usual actions of physical therapists in Argentina (Table 2), 36.7% reported experiencing no major limitations when mobilizing a patient. The highest reported mobility goal for patients undergoing invasive MV was optimizing muscle strength, followed by sitting on the edge of the bed. The highest mobility goal for patients who have been successfully weaned from invasive MV was performing activities of daily living (ADLs), followed by walking. The highest mobility goal reported for patients who had never required MV was performing ADLs, followed by walking ( Figure 1).
A total of 56.4% of the respondents did not use goalbased validated tools to assess the physical condition of their patients in the ICU. Among those who did use them, the Medical Research Council (MRC) and Barthel index were among the most frequently used (Table 3).
Regarding the third section (Table 4), which pertained to early mobility therapy in patients with confirmed or  Another factor that was discussed is the probable relationship between the lack of mobilization protocols and the proposed treatment goals. Hanekom and Elliott described the benefits and outcome improvements in centers that use mobilization and analogous sedation protocols compared to those that do not. (19,20) We believe that combining work protocols, the current open ICU concept family empowerment (21) and reviews of the goals for each treatment session could improve the outcomes of critically ill patients.
Regarding barriers or limitations, although the response options provided in the survey reflected the barriers and limitations most frequently reported in the literature, (22,23) our respondents most often selected "none of the above". A possible explanation for this finding is an error in the wording or interpretation of the question; the respondents may have interpreted this option as indicating the absence of any limitations. It should be clarified that this option was added after the expert review and pilot test.

DISCUSSION
The present survey describes the responses of 351 physical therapists working in adult ICUs in Argentina regarding their usual practice of mobility therapy and how the pandemic has influenced it.
Regarding the proposed treatment goals for the three scenarios, patients receiving MV were assigned the lowest treatment goal, while patients in the other two scenarios were assigned the highest goal ( Figure 1). These findings may suggest that for the surveyed physical therapists, MV in itself is a limitation to progressing with different motorbased treatment strategies. These beliefs may be installed in the culture of intensive therapies, which is permeated by the belief that intensive care patients are too sick to tolerate any activity and that functional deterioration is inevitable after a critical illness. (17) For patients receiving MV, the highest motor-based goal was optimizing muscle strength. In South America, Pires-Neto et al. reported that more than half of the activities that were carried out in patients with MV were related to in-bed mobilization. (18) Schweickert et al. (11) described that although preventive mobility therapy did not restore muscle strength, it enabled functional rehabilitation in this group of patients. In line with this, we consider it necessary to review the therapeutic targets proposed for each scenario in future research. On the other hand, the participants indicated that the limitations for treating patients with confirmed or suspected COVID-19 were respiratory and/or contact isolation, followed by a lack of personal protective gear, results similar to those reported by Valenzuela et al. (14) It is likely that health personnel in general have become more aware of the importance of personal care, and this awareness forces them to choose the optimal moment for intervention and rely on available material in developing their activities. We believe that in this sense, the pandemic has forced healthcare providers to review how they perform their "usual" and will likely generate changes in work attitudes going forward.
Finally, the MRC and Barthel index scales were the tools most frequently used for assessing the physical condition of patients, consistent with the findings of other local studies. (24,25) Castro-Avila et al., (26) in their systematic review and meta-analysis, reported that the 6-minute walk test and timed up-and-go test were the most commonly used tools for assessing physical condition upon ICU discharge. These findings suggest that the tools selected by our respondents may not necessarily represent the physical condition of critical patients upon ICU discharge.
The present survey recorded the responses of physical therapists working in Argentina regarding mobility therapy in ICUs. These practices were previously unknown; they have been minimally studied, and the related terminology and results are heterogeneous and nonspecific. In this sense, we believe that the results of our study are valuable for laying the foundations for future research and can deepen and generalize findings in such areas as goal-driven assessment strategies, which in turn will allow possible preventive and/or treatment approaches to be proposed.
As limitations, we can highlight that the multiple-choice response format could have restricted the respondents' responses. In turn, the recruitment of participants through social networks could have generated selection bias. We believe that with a longer dissemination time, our results could have had greater reach and thus reflected the reality at the national level, rather than mainly focusing on the Autonomous City of Buenos Aires and in the Province of Buenos Aires. Finally, it is necessary to develop prospective studies to compare the functional outcomes of COVID-19-positive patients and patients without COVID-19 at discharge from intensive therapy and in the long term.

CONCLUSION
The physical therapists surveyed in Argentina reported being responsible for the mobility of patients in the intensive care unit. The highest goal for patients under mechanical ventilation was to optimize muscle strength and make progress towards performing activities of daily living without limitations.
Regarding patients with COVID-19, the greatest limitation for mobilization was respiratory/contact isolation, while the highest goal for patients under mechanical ventilation was optimizing muscle strength.