title: Effects of early, combined endurance and resistance training in mechanically ventilated, critically ill patients: a study protocol for a randomised controlled trial.
abstract: Prolonged need for intensive care is associated with neuromuscular weakness, termed Intensive Care Unit Acquired Weakness. Those affected suffer from severe functional impairment that can persist for years. First studies suggest a positive effect of physiotherapy and early mobilisation. However, the ideal intervention for a preferential functional outcome is not known. So far no randomised controlled trial has been conducted to specifically evaluate an early endurance and resistance training in the mechanically ventilated, critically ill patient.
  
  
  
  A randomised controlled trial with blinded assessors and 6-month follow-up will be conducted in a tertiary, interdisciplinary intensive care unit in Switzerland. Participants (n = 115; expected dropouts: n = 15) will be randomised to a control group receiving standard physiotherapy and to an experimental group that undergoes early mobilisation combined with endurance and resistance training. The inclusion criteria are being aged 18 years or older, expected mechanical ventilation for more than 72 h and qualitative independence before the illness. Primary endpoints are functional capacity (6-Minute Walk Test) and the ability to perform activities of daily living (Functional Independence Measure) measured at hospital discharge. Secondary endpoints include muscle strength (Medical Research Council sum score, handgrip strength and handheld dynamometry for quadriceps muscle), joint contractures (range of motion), exercise capacity (Timed 'Up & Go' Test) and health-related quality of life (Short Form 36). Safety will be monitored during interventions by indirect calorimetry and continuous intensive care standard monitoring. All previously defined adverse events will be noted. The statistical analysis will be by intention-to-treat with the level of significance set at p < 0.05.
  
  
  
  This prospective, single-centre, allocation-concealed and assessor-blinded randomised controlled trial will evaluate participant's function after an early endurance and resistance training compared to standard care. Limitations of this study are the heterogeneity of the critically ill and the discontinuity of the protocol after relocation to the ward. The strengths lie in the pragmatic design and the clinical significance of the chosen outcome measures.
  
  
  
  German Clinical Trials Register (DRKS): DRKS00004347 , registered on 10 September 2012.
authors.affiliation: Department of Physiotherapy, Inselspital, Bern University Hospital, Bern, 3010, Switzerland. sabrina.eggmann@insel.ch.
authors.forename: Sabrina
authors.initials: S
authors.lastname: Eggmann
authors.affiliation: Department of Physiotherapy, Inselspital, Bern University Hospital, Bern, 3010, Switzerland.
authors.forename: Martin L
authors.initials: ML
authors.lastname: Verra
authors.affiliation: Department of Physiotherapy, Inselspital, Bern University Hospital, Bern, 3010, Switzerland.
authors.forename: Gere
authors.initials: G
authors.lastname: Luder
authors.affiliation: Department of Intensive Care Medicine, Inselspital, Bern University Hospital and University of Bern, Bern, 3010, Switzerland.
authors.forename: Jukka
authors.initials: J
authors.lastname: Takala
authors.affiliation: Department of Intensive Care Medicine, Inselspital, Bern University Hospital and University of Bern, Bern, 3010, Switzerland.
authors.forename: Stephan M
authors.initials: SM
authors.lastname: Jakob
mesh_terms: D000203:Activities of Daily Living; D001696:Biomechanical Phenomena; D002985:Clinical Protocols; D016638:Critical Illness; D004434:Early Ambulation; D017079:Exercise Tolerance; D006801:Humans; D007362:Intensive Care Units; D057194:Intention to Treat Analysis; D009119:Muscle Contraction; D053580:Muscle Strength; D053581:Muscle Strength Dynamometer; D018908:Muscle Weakness / Q000175:diagnosis / Q000503:physiopathology / Q000534:rehabilitation*; D018482:Muscle, Skeletal / Q000503:physiopathology*; D010807:Physical Endurance; D011446:Prospective Studies; D011788:Quality of Life; D020127:Recovery of Function; D012107:Research Design; D055070:Resistance Training / Q000009:adverse effects; D012121:Respiration, Artificial / Q000009:adverse effects; D011795:Surveys and Questionnaires; D013557:Switzerland; D013997:Time Factors; D016896:Treatment Outcome; D000070857:Walk Test
keywords: Critical illness; Intensive care; Mechanical ventilation; Physical function; Physiotherapy; Rehabilitation; Weakness