Download PDFPDF

Original Article
Intensive versus standard physical rehabilitation therapy in the critically ill (EPICC): a multicentre, parallel-group, randomised controlled trial
Compose Response

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
Author Information
First or given name, e.g. 'Peter'.
Your last, or family, name, e.g. 'MacMoody'.
Your email address, e.g.
Your role and/or occupation, e.g. 'Orthopedic Surgeon'.
Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.
Statement of Competing Interests


  • A rapid response is a moderated but not peer reviewed online response to a published article in a BMJ journal; it will not receive a DOI and will not be indexed unless it is also republished as a Letter, Correspondence or as other content. Find out more about rapid responses.
  • We intend to post all responses which are approved by the Editor, within 14 days (BMJ Journals) or 24 hours (The BMJ), however timeframes cannot be guaranteed. Responses must comply with our requirements and should contribute substantially to the topic, but it is at our absolute discretion whether we publish a response, and we reserve the right to edit or remove responses before and after publication and also republish some or all in other BMJ publications, including third party local editions in other countries and languages
  • Our requirements are stated in our rapid response terms and conditions and must be read. These include ensuring that: i) you do not include any illustrative content including tables and graphs, ii) you do not include any information that includes specifics about any patients,iii) you do not include any original data, unless it has already been published in a peer reviewed journal and you have included a reference, iv) your response is lawful, not defamatory, original and accurate, v) you declare any competing interests, vi) you understand that your name and other personal details set out in our rapid response terms and conditions will be published with any responses we publish and vii) you understand that once a response is published, we may continue to publish your response and/or edit or remove it in the future.
  • By submitting this rapid response you are agreeing to our terms and conditions for rapid responses and understand that your personal data will be processed in accordance with those terms and our privacy notice.
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Vertical Tabs

Other responses

Jump to comment:

  • Published on:
    The EPICC trial, is it possible to perform intensive rehabilitation in the current framework of intensive care?
    • Anthony Fung, Core Medical Trainee Surrey and Sussex Healthcare NHS trust
    • Other Contributors:
      • Ann-Marie Evans, Physiotherapist
      • Alice E. Myers, Consultant in Anaesthesia and Intensive Care Medicine
      • Theophilus L. Samuels, Consultant in Anaesthesia and Intensive Care Medicine

    The EPICC trial addresses the rarely investigated topic of rehabilitation in the critical care setting [1]. We note with interest that no improvement was found in outcomes in the rehabilitation group compared to the standard treatment group. Some of the reasons are clearly highlighted by Schaller et al. in their response to the paper including the time to starting intervention, therapy times and also sample size. Only 41% of the participants in the intervention group and 35% of the standard treatment group contributed data throughout the study period. In addition to this, only 8% of the intervention group managed over half the target therapy time and the EPICC trial showed that ‘an extra 10 minutes of physical therapy per day does not make a difference [2]’
    This study triggered an audit within our own 16 bedded mixed surgical and medical intensive care department assessing the number of sessions carried out over a 2 week period compared to those attempted. We investigated the actual duration of sessions achieved as compared to a target of 45 minutes rehabilitation each day during the working week (Monday-Friday). On average, 23.3 (standard deviation 20.19 minutes) minutes of rehabilitation per day was achieved and only 35% of attempted physical therapy sessions were completed. These figures are similar to those cited within the EPICC trial and highlight some of the difficulties of achieving longer therapy times within a busy intensive care department. Some of the fac...

    Show More
    Conflict of Interest:
    None declared.
  • 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...

    Show More
    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.


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

    Show More
    Conflict of Interest:
    None declared.