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Intensive versus standard physical rehabilitation therapy in the critically ill (EPICC): a multicentre, parallel-group, randomised controlled trial
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  • Published on:
    What does the EPICC trial really tell us?
    • Stefan J Schaller, Anesthesiologist Intensivist Klinikum rechts der Isar der TUM, Munich, Germany
    • Other Contributors:
      • Peter Nydahl, Research Nurse
      • Manfred Blobner, Professor of Anesthesiology
      • Nicola Latronico, Professor of Anesthesia and Critical Care Medicine
      • Carol Hodgson, Associate Professor and Deputy Director, ANZIC-RC

    We have read with great interest the multi-centred EPICC trial that randomized over 300 patients [1]. While the delivery of a complex physical rehabilitation intervention in clinical trials is difficult, we believe that several aspects of the trial may have resulted in the inability to detect a difference between the control and intervention groups. These factors include the delayed time to start the intervention, inadequate delivery of the intervention and the large loss to follow-up for the primary outcome measure. In our opinion, these three factors limit the interpretation of the results of the study. While the authors have mentioned some of these concerns in their discussion, and Connolly et al. raised some of these points already [2], we hope to learn some important lessons from the authors to better understand these limitations and how they can be minimized in future studies.
    The number of randomized controlled trials evaluating early physical rehabilitation in ICUs is increasing [3]. Positive effects on primary outcomes were only found in studies in which physical rehabilitation was started within 72 hours of ICU admission [4-6]. Studies, which did not meet this criterion of early onset of physical rehabilitation, did not demonstrate benefit of the intervention [7]. Therefore, this time frame has been defined in rehabilitation guidelines [8]. Based on this evidence, we are not surprised that the authors of the EPICC trial were unable to demonstrate beneficial...

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    Conflict of Interest:
    None declared.
  • Published on:
    Intensive or longer?
    • Rodrigo Santos Queiroz, college professor Department of Health of Southwestern State University of Bahia - Brazil
    • Other Contributors:
      • Micheli Bernardone Saquetto, college professor
      • Bruno Prata Martinez, college professor
      • Mansueto Gomes Neto, college professor

    We read with great interest the article by Wright et al (1) published recently on the Thorax. We congratulate the authors for the study that focused on an important issue, an optimal dose of mobilization in critically ill patients. This is a very well designed clinical trial that allows us to delve deeper into discussions about training load variables applied to critical patients.
    The authors named the main study training load variable of intensity. However we note that the duration of the program was the main difference between the groups and not the intensity. This is, because duration is the time period for a specific activity, while the intensity is relative to the rate of energy expenditure required to perform the activity (aerobic activity) or the magnitude of the force exerted during the resistance exercise (2).
    It was unclear how muscle strength training progressed and there was no measure of energy expenditure (even if indirectly with accelerometers or perceived exertion scales), so we can not clearly state that there was a difference in the intensity of the groups, even though they had a longer duration for the intervention group (3). It is well known that in healthy subjects, shorter duration and shorter intervals may have substantially higher energy expenditure and may affect the metabolic pathways differently (4). A reality that still deserves more attention in intensive care mobilization studies.

    References

    1. Wright SE, Thomas K, Wa...

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    Conflict of Interest:
    None declared.