Effect of Early Rehabilitation Using an Active/Passive Cycling Device on Muscle Wasting in the Critically Ill: A Randomised Controlled Study
Phase: NA
Conditions: Muscle Weakness
Sponsor: University of Liverpool

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Effect of early rehabilitation using an active/passive cycling device 
on muscle wasting in the critically ill:  
A randomised controlled pilot study 
 
Short Title – Muscle Wasting in the Critically Ill. 
 
 
Turton P, Dyson S, Jenions L, Barrett-Jolley R, Gunther M, Connolly B, 
Welters ID 
 
Dr Peter Turton, MBChB(Hons) MPhil FRCA 
Version 19.0, 15th June, 2018 (FINAL) 
IRAS Number : 235656 
 

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1. Signature page 
 
 
 
Professor I. Welters, Chief Investigator  
 
 
………………………. 
 
 
Dr P Turton, Academic Clinical Fellow 
 
 
 
………………………. 
 
 
Karen Williams, Lead Research Nurse  
 
 
………………………. 
 
 
 
Other staff: 
 
Please see delegation log 
 
Name 
Role 
Signature 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Contents 
Title page 
 
 
 
 
 
 
 
 
 
1 
Signatures 
 
 
 
 
 
 
 
 
 
2 
Contents 
 
 
 
 
 
 
 
 
 
3-4 
Abbreviations and definitions 
 
 
 
 
 
 
5-6 
Summary 
 
 
 
 
 
 
 
 
 
7-8 
Background  
 
 
 
 
 
 
 
 
9-14 
 
ICU Acquired Weakness 
 
 
 
 
 
 
9-10 
 
Physical methods of preventing and treating muscle loss 
 
9-12 
 
Scientific rational 
 
 
 
 
 
 
 
12-14 
Trial objectives and purpose 
 
 
 
 
 
 
15-20 
 
Research questions  
 
 
 
 
 
 
15-17 
 
Study design  
 
 
 
 
 
 
 
17 
 
Subject selection 
 
 
 
 
 
 
 
17-19 
 
Subject recruitment  
 
 
 
 
 
 
19-20 
Trial interventions and investigations 
 
 
 
 
 
21-25 
Patient end points  
 
 
 
 
 
 
 
25 
Data to be collected  
 
 
 
 
 
 
 
25 
Other data collected 
 
 
 
 
 
 
 
27 
Further laboratory studies  
 
 
 
 
 
 
28 

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Statistical analysis  
 
 
 
 
 
 
 
28-29 
Blinding 
 
 
 
 
 
 
 
 
 
29 
Ethical considerations 
 
 
 
 
 
 
 
29-30 
End of study, dissemination and archiving 
 
 
 
 
30-31 
 
Appendix A – Study flow diagrams 
 
 
 
 
 
32-33 
Appendix B – The CYCLE trial exclusion criteria 
 
 
 
34-35 
Appendix C – Proposed measurements and statistical tests  
 
36 – 38 
References  
 
 
 
 
 
 
 
 
39-43 
 
 
 
 
 
 
 

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Abbreviations and definitions 
6MWT 
 
Six minute walk test 
APACHE II  
Acute Physiology And Chronic Health Evaluation II 
BMI 
 
 
Body Mass Index 
CAM-ICU 
 
Confusion Assessment Method for the ICU 
DTF 
Diaphragmatic Thickening Fraction (the ratio of muscle 
thickness at expiration compared to inspiration). 
FES  
 
Functional Electrical Stimulation 
FEV1  
 
Forced Expiratory Volume in 1 Second 
FVC  
 
Forced Vital Capacity 
Hz 
 
 
Hertz – a unit of frequency required for FES 
ICNARC 
 
Intensive Care National Audit & Research Centre 
ICU   
 
Intensive Care Unit 
ICU-AW 
 
Intensive Care Unit Acquired Weakness 
IL (6, 8, etc)  
Interleukin 
mA 
 
 
Milli-amperes – a unit of current required for FES 
MRC  
Medical Research Council.  In this context it refers to the MRC 
Sum Power Score, a subjective scale testing power in major 
muscle groups. 
NMES  
 
Neuro-muscular Electrical Stimulation 

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PFT 
 
 
Pulmonary Function Test 
SF-36  
 
Short Form Health Survey (with 36 items) 
SOFA  
 
Sequential Organ Failure Assessment 
 
 
 
 

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Summary 
The aim of this randomised controlled pilot trial is to assess whether a 14-day course 
of cycling with Functional Electrical Stimulation (FES) can prevent muscle loss and 
preserve muscular function in septic patients who are sedated, intubated and 
mechanically ventilated in the ICU, compared to a control group of patients who will 
receive standard daily physiotherapy. 
It is known from several studies that muscle size significantly decreases early in a 
patient’s admission to critical care with sepsis. This rapid muscle loss is likely due to 
a combination of disuse atrophy and systemic inflammation. Passive movement and 
stretching exercises performed by physiotherapists, do not appear to prevent muscle 
loss. Previous studies with electrical nerve stimulation have provided mixed results 
with respect to preserving muscle thickness. The proposed study differs from 
previous investigations in that we will use a cycling device which passively moves 
the participants legs whilst they are in bed, sedated and on a breathing machine, but 
with the addition of low current electrical stimulation applied on leg muscles, so that 
they can contract and relax in time with the movement of the cycle, thus providing 
“functional stimulation” rather than just electrical stimulation. 
Briefly, we intend to enrol participants into the study within 48 hours of being 
intubated and mechanically ventilated for sepsis. Ultrasound measurements of the 
leg muscles, abdominal musculature and diaphragm will be performed, alongside 
baseline blood and urine sampling. Muscle biopsies will be taken from the leg before 
and after the 14-day study period. These biological samples will serve to investigate 
cellular mechanisms involved in muscle wasting as part of a separate translational 
follow-up research project. 

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This pilot study includes ultrasound measurements of different muscle groups and 
clinical outcomes in the intervention and control group and will allow us to define the 
most pragmatic and clinically relevant primary outcome measure for larger multi-
centre trials. 
  
Those randomised to the intervention will be in the study for 14 days.  They will 
receive five 30 minute treatments with the device per week.  Therefore in a 14 day 
period, they should receive 10 treatments.   
Repeat ultrasound measurements will be taken on days 3, 5, 7, 10 and 14.  Further 
blood and urine samples will be taken on days 5, 10 and 14.  A second muscle 
biopsy will be taken on day 14.   
Should patients be liberated of mechanical ventilation before day 14, they will 
continue in the trial, providing that they provide consent to do so. 
All survivors from the trial will be invited to a follow up study 3 months from hospital 
discharge, where further ultrasound assessments, plus assessment of balance, 
strength and psychological wellbeing will be assessed. 
There are two broad aims to this study. The first is to identify the clinically most 
useful measurement of changes in muscle size by investigating a number of muscle 
groups, using several indices of muscle size. This will inform us of the most suitable 
primary outcome for further follow-up studies. 
The second aim is to assess the safety profile and feasibility of the study. 
Specifically, we will determine the number of successfully completed cycling 

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sessions, identify logistical hurdles and patient safety risks, such as haemodynamic 
deterioration or accidental extubation.  
 
 

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Background 
ICU Acquired Weakness 
Intensive Care Unit Acquired Weakness (ICU-AW) is a common and potentially 
debilitating consequence of admission to an intensive care unit with critical illness(1).   
It is defined as a diffuse generalised muscle weakness without a readily identifiable 
cause, which occurs after developing a critical illness.  Nerve conduction studies and 
electromyography often demonstrate both polyneuropathy and myelopathy(2).  
Patients with critical illness, having survived the initial acute insult, are often left with 
long term problems with mobility(3), which preclude independent living even five 
years after hospital discharge(4).  These long-term sequelae represent a massive 
burden on both the health service and the patients’ families and caregivers in the 
community(5). 
Muscle size, expressed as either muscle thickness or muscle cross-sectional area of 
muscle in the limbs, can be easily tracked using bedside ultrasound methods(6). As 
well as size and cross-sectional area of muscles, further information, such as the 
arrangement of fascicles within the muscle (known as the muscle architecture)(7) 
and ultrasound echogenicity(8), can also be easily obtained at the bedside.  
Echogenicity is helpful in determining infiltration of muscle with fat or fibrosis, which 
usually occurs as a result of disease or aging(9).  These methods have been shown 
to have good reliability and accuracy in adult critically ill patients(10). Our own work 
has demonstrated that patients lose over 10% of their muscle thickness in the first 96 
hours of mechanical ventilation, and that by 10 days, 28% of muscle thickness was 
lost(7).   Changes to the arrangement of the fascicles within the muscle also occur, 
with pennation angle reducing over time, suggesting that weakness may occur 

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through loss of force generation as a result of smaller pennation angles.  These 
results are in keeping with another recent study which demonstrated a 30% 
reduction in muscle thickness in the vastus intermedius in critically ill patients over 
10 days(6) and far exceeds the previously demonstrated loss of 8% muscle 
thickness over five weeks bed rest in healthy volunteers(11). Ultrasound 
measurement of the quadriceps femoris muscle has shown a negative relationship 
between length of stay in critical care and muscle size during the admission(12). 
These structural changes are associated with loss of individual fibre area, increased 
loss of protein, and decreased protein synthesis, in comparison to healthy 
controls(13). 
 
Physical methods of preventing and treating muscle loss 
Supine cycling 
Early mobilisation of patients has been shown to improve to outcomes in patients 
who survive critical illness(14).  There are randomised control trials being carried out 
at present, looking at supine cycling in patients in critical care(15).  Such cycling 
sessions can be active (entirely initiated by the patient), passive (the patient’s legs 
are moved for them by the cycle, but no effort comes from the patient,) or assisted 
(where the patient makes the initial effort to move, and is then supported by the 
cycling device).  Previously reported smaller trials have shown that the technique is 
safe, can be carried out in sedated patients, and can be performed safely whilst the 
patient is receiving intravenous infusion therapies(16).  Another randomised control 
trial, the MoVe-ICU study, is currently in progress, examining how passive cycling in 
the early stages of critical illness will change the muscle morphology and ultrasound 

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appearance of leg muscle in these patients(17).  It is, however, currently known 
whether early passive cycling during critical illness compared to standard treatment 
does improve 6-minute walk test scores in patients who survive critical illness(18). 
 Neuromuscular stimulation 
Neuromuscular electrical stimulation (NMES) has been shown to improve muscle 
strength and balance in patients outside of ICU, for example stroke survivors(19). 
NMES used in patients after discharge from ICU resulted in no difference in muscle 
layer thickness, but did recover muscle strength more quickly compared to 
controls(20).  In patients who received NMES whilst still mechanically ventilated, 
walking distance on discharge was greater than those receiving a sham therapy, but 
there was no difference in lower limb extremity muscle strength(21).  The technique 
itself however has been shown to be safe and simple to carry out(22). 
 
 Functional Electrical Stimulation 
Functional electrical stimulation (FES) also involves the use of electrically stimulating 
the muscles of the leg, but has been combined with a cycling device in order to carry 
out supine cycling exercises in patients who are still sedated. This device has been 
trialled in stroke patients, where it has improved muscle strength and function 
outcomes in a number of settings(23)(24), in comparison to passive cycling.  Gait 
and posture have also been shown to improve after FES cycling(25). 
In the critical care population, a case-control study has shown that FES with cycling 
improves physical function and reduces the incidence of delirium(26).  

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NMES and FES, whilst both using electrical current to stimulate muscle contraction, 
are distinct treatment modalities. NMES requires the delivery of low voltage 
electricity to muscles directly underneath surface electrodes which are placed on the 
skin(27).  Studies using NMES have focussed on one muscle group per study.  FES 
differs from NMES in that different muscle groups are stimulated in an alternating 
pattern.  The addition of cycling allows for a muscle group to be recruited via 
electrical stimulation, whilst its antagonistic muscle group is relaxed.  This stimulating 
pattern is then reversed so that the relaxed muscle is contracted, and the contracted 
muscle is relaxed. 
There is an on-going randomised control trial, (eStimCycle – Early Rehabilitation in 
Critical Care, register with clinicaltrials.gov, trial identifier NCT02214823) in which 
patients with sepsis who are mechanically ventilated for longer than 48 hours, are 
being randomised to receive FES with cycling in one leg, with the other leg receiving 
no FES but still undergoing passive cycling, or randomised to a control group of 
standard physiotherapy(28).  Our proposed trial will differ in the following ways: 
• 
Both legs will be treated with FES with cycling. Comparison will be made with 
a separate control group receiving standard physiotherapy. 
• 
In addition, the rectus abdominis muscle will be stimulated to assess if core 
muscle strength improves. 
• The effects on other organ systems, including changes to the diaphragm and 
anterior abdominal wall muscles, will be investigated alongside changes to the 
lower limb.  These are detailed in the methods section. 
 
 

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Scientific rationale 
Immobility, independently of illness, leads to rapid muscle wasting.  This atrophy is 
largely mediated through transcription of a range of “atrogenes”; including elements 
of the autophagic and ubiquitin proteasome systems(29).  The final common path 
appears to be similar in disuse in volunteers and in ICU-AW patients, but in disease 
states additional intracellular pathways lead to atrogene transcription, resulting in a 
more rapid and exaggerated atrophy.  Direct comparison of immobilised or bed- 
rested healthy individuals with ICU-AW patients are plagued with numerous 
confounding variables, but as a guide the former may lose 0.6% muscle size per 
day, whilst our data show that ICU-AW patients routinely loose about 2.5% per 
day(7).  This figure is similar to the loss of force seen (thumb muscle) in ventilated 
critical care patients (30% over 14 days)(30).  
In healthy individuals exercise promotes synthesis of muscle contractile proteins and 
supresses a range of pathways that induce atrogene transcription.  In a wide range 
of diseases, cytokines activate the NFkB system that in turn promotes atrogenesis.  
The role of NFkB signalling itself is complex with both exercise and disuse reported 
to increase activity(31)(32)(33)(34)(35).  Reactive oxygen species (ROS) are 
elevated in older, frail people, and this also triggers NFkB activation(36).  A further 
pathway leading to atrogene transcription is myostatin-SMAD. This system is 
activated in a number of situations including ageing and critical care, but its 
physiological regulation is largely unknown(37).  Therefore, a typical older ICU-AW 
patient will have a conflagration of several different intracellular pathways that lead to 
autophagy, mitochondrial and myofibril degradation. In this project, we will use 
muscle biopsies from patients undergoing FES with supine cycling, and control 
patients to identify the intracellular pathway changes that underlie muscle 

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preservation.  In particular, it is important that we identify which intracellular pathway 
changes correlate with muscle preservation, or lack thereof, so that future 
intervention studies can establish whether this relationship is causal and devise 
novel therapeutic interventions that could be deployed independently of FES. 
Cytokines have been implicated in the development of ICU-AW, and a recent study 
has shown that in a cohort of patients who developed ICU-AW, high levels of the 
interleukin (IL) -6, IL-8, IL-10 and fractalkane were found, in comparison to critically 
ill patients who did not develop ICU-AW(38).  Raised cytokine levels may cause 
muscle damage through poor oxygenation of muscle(39).  This may potentially be 
explored via a non-invasive infra-red spectroscopy technique(40).  
 
 

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Trial objectives and purpose 
The main objective is to perform a randomised controlled pilot study to assess the 
effects of daily cycling with functional electrical stimulation in sedated and 
mechanical ventilated intensive care patients. We will measure several indices of 
muscle size in a number of muscles groups over a 14-day period. The second 
objective is to assess the feasibility of the study protocol, so that if required, study 
procedures can be refined for a definite randomised control trial. 
 
Justification for a pilot study: 
A wide variation in the use of electrical stimulation in the critically ill and the effects 
on muscle thickness has been reported in previous studies. A structured review 
found four studies, each assessing the effect of electrical stimulation on different 
muscle groups(41). Whilst two studies found that the muscle studied decreased, 
even with stimulation, a third study found no change to the size of the muscle, whilst 
a fourth demonstrated and increase in size. Furthermore, a study of critically ill 
patients on muscle wasting in the abdominal muscles, demonstrated that electrical 
stimulation slowed muscle loss in the critically ill compared to patients who did not 
receive it(42).  The potential to increase thickness of abdominal muscle groups with 
neuromuscular stimulation has been demonstrated before, albeit in healthy 
volunteers(43).  A pilot study, consisting of a number of muscle groups and 
measurement parameters, would allow us to refine the protocol to define the most 
pragmatic and clinically relevant primary outcome measure for a later definitive trial. 
 
 

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Research objectives: 
Research objectives regarding muscle thickness and function: 
1. What is the effect of a 14day course of 30 minutes cycling with functional 
electrical stimulation, consisting of 10 treatments over 14 days, on muscle 
thickness, cross-sectional area, fascicle pennation angle, fascicle length and 
echogenicity of the following muscles, compared to a control group receiving 
standard daily physiotherapy: 
a) Vastus lateralis – all measurements 
b) Rectus femoris, vastus medialis, vastus intermedius – cross sectional area 
and echogenicity 
c) Medial head of gastrocnemius – all measurements 
d) Rectus abdominis – Cross section area and echogenicity 
e) Diaphragm – muscle thickness, thickening fraction and maximal excursion 
2. Are such differences between treatment and control group maintained 3 
months after hospital discharge?   
3. Does treatment with FES and cycling affect other organ systems, as defined 
by requirement for renal replacement therapy, inotropic/vasopressor support, 
time to wean from ventilation, and incidence of delirium? 
4. Do ultrasonic muscle changes correlate with biochemical alterations 
measured in serum and muscle tissue? The details of these changes will be 
described in a separate study protocol. 
Research objectives to assess feasibility and patient safety:  

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1. How many of the 10 sessions can be successfully completed in a 14-day 
period? Successful completion will comprise at least 20 min of cycling activity.  
2.  What are the reasons for missed or incomplete treatment sessions? 
3. What is the incidence of adverse effect such as haemodynamic changes 
(blood pressure or heart rate) of more than 20% baseline, central or arterial 
line dislodgement, accidental extubation or falls? 
 
Study design 
We intend to perform a randomised control pilot trial with two arms: 1. Patients 
receiving standard physiotherapy will serve as a control group, 2. Patients 
undergoing FES plus supine cycling 5 times per week. In a number of muscle 
groups, muscle thickness will be measured with ultrasound to determine the clinically 
most useful index to describe changes in muscle size during treatment with 10 
sessions of FES with cycling over a 14-day period.   
 
Subject selection 
Patients will be recruited in the Intensive Care Unit of the Royal Liverpool University 
Hospital.  All patients will be over 18, and have a critical illness that requires 
mechanical ventilation with an initial period of sedation.  This study will focus on 
patients with a definite or suspected case of sepsis from any source.   
Sepsis has been recently redefined as: “Life threatening organ-dysfunction caused 
by dysregulated host response to infection” whilst septic shock has become a subset 

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of sepsis, defined as: “circulatory and cellular/metabolic dysfunction associated with 
a higher risk of mortality(44). 
For the purposes of this study, a patient will be regarded as septic if they have 
evidence of infection-related organ failure (e.g. sepsis-associated coagulopathy, 
altered mental state, cardiovascular dysfunction, acute kidney injury, and altered 
liver function) and require invasive mechanical ventilation with either definite or 
suspected evidence of infection.  This is to allow prompt treatment with FES rather 
than waiting for a positive microbiological result to be obtained. 
Within the definition of sepsis “from any source” a list of following is illustrative but 
not exhaustive: 
• Urogenital sepsis (including urosepsis, pyelonephritis, endometritis and 
chorioamnionitits) 
• Pneumonia (including community acquired, hospital acquired, and aspiration 
pneumonia.  Ventilator associated pneumonia would be excluded.) 
• Neurological infections such as encephalitis and meningitis. 
• Cellulitis, osteomyelitis and infections of soft tissue NOT affecting the lower 
limb. 
• Surgical infections, including post-operative laparotomy with evidence of 
peritoneal soiling, and evidence of infection prior to the operation, in patients 
who require 2 or more organ system support after the operation. 
• Intra-abdominal sepsis, including biliary sepsis, hepatitis, and acute 
pancreatitis.  In the case of acute pancreatitis, evidence of infection is 
required to fulfil the criteria.  Acute pancreatitis with sterile tissue/fluid samples 
would not be suitable. 

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Exclusion criteria include: 
• Patients under 18 
• Patients who decline consent  
• Pregnancy 
• Neuromuscular disease 
• Rhabdomyolysis 
• Lower limb trauma 
• Patients unlikely to survive to 96 hours post admission 
• Consent unobtainable within 48 hours of admission 
• Morbid obesity (BMI>40). 
• Presence of a pacemaker or Implantable Cardiac Defibrillator (ICD). 
• Unlikely to be mechanically ventilated for more than 48 hours. 
 
Subject recruitment 
Patients will be mechanically ventilated and sedated and therefore unable to consent 
to the trial.  The patient’s next of kin will be approached to act as a consultee, to 
provide consent for the patient to take part in the study. If the patient regains 
capacity to consent for themselves, they will be informed about their participation in 
the study and retrospective consent will be sought.   
The process for taking consent from the next of kin is as follows: 
Patients will be screened every morning by the research nursing team to identify 
potential patients who meet the inclusion criteria. Eligible patients will be discussed 
with the medical team that day to assess if the medical condition or comorbidities 

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preclude recruitment into the trial (for example, the medical team have decided to 
withdraw care). 
The next of kin will be approached by a member of the research team.  The aims of 
the study and a discussion of what would happen to their relative during the trial will 
take place, and an information leaflet will be given to the next of kin. At this point, 
there is no obligation to sign a consultee declaration form. The next of kin will be 
given time to think about whether they want their relative to take part, and they can 
discuss the study with other members of the family.  
Once the next of kin has decided to provide consent, they will sign a consultee 
declaration form, acting as a consultee on behalf of their relative.  Should they later 
decide to withdraw this declaration, the patient will be withdrawn from the study, and 
all samples and data will be disposed of. 
Once the patient regains capacity, they will be approached by the research team, 
explaining the involvement in the study so far, the aims of the study, and what will 
happen if they agree to continue in the study.  They will again be given time to think 
about whether they want to continue in the study, and will be given an information 
leaflet to read.  There is no time limit on this, and once ready, the patient will have to 
provide retrospective consent by signing the appropriate retrospective consent form. 
Should they decide they do not want to take part in the study, all further cycling 
sessions would be cancelled.  An added option has been incorporated into this form, 
in the event that the patient decides they do not want any more cycling sessions, but 
that we can continue to store and use blood, urine and muscle biopsy samples, and 
that no further samples will be taken.  In the event that they do not consent to us 
using pre-existing samples, and they do not want any further cycling sessions, then 

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all samples will be destroyed.  This includes the deletion of ultrasound images from 
any storage medium. 
 
Where a next of kin cannot be contacted within 36 hours of admission, a professional 
consultee declaration by the patient’s clinical team will be considered to allow 
recruitment into the study within the 48h time frame. The senior clinician in the 
medical team will be provided with an information leaflet, and when ready, will be 
given a Nominated Professional Consultee Declaration form to sign. 
Patients for whom a consultee declaration form cannot be signed within 48h after 
intubation, will need to be excluded from the trial. 
 
Trial interventions and investigations 
The day on which a valid consultee declaration is obtained, will be classified as Day 
0.  Within 24 hours, patients will receive an ultrasound of the vastus lateralis to 
assess muscle thickness and fascicle pennation angle, and ultrasounds of the four 
heads of the quadriceps (rectus femoris, vastus lateralis, medialis and intermedius), 
medial head of gastrocnemius, rectus abdominis and diaphragm. Blood and urine 
samples will be taken from pre-existing arterial (or central venous) lines and urinary 
catheters. A percutaneous muscle biopsy will also be taken under sedation and local 
anaesthesia from the vastus lateralis muscle.  All samples will be obtained on study 
day 1 before the intervention is started. 
Ultrasound scanswill be repeated on days 3,5, 7, 10 and 14. Our work and previous 
publications suggest that significant losses in muscle thickness can be detected by 

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ultrasound as early as day 5, and are more pronounced by day 10.  Further blood 
and urine samples will be taken on days 5, 10 and 14. 
Ultrasound scanning of the following muscles will take place on day 1: 
• Vastus lateralis  
• Rectus femoris Vastus lateralis, intermedius and medialis (cross section 
area). 
• Medial head of gastrocnemius 
• Diaphragm 
• Rectus abdominus 
All ultrasound scans will be taken with the patient lying supine. Vastus lateralis and 
rectus femoris imaging will be performed with the limbs straight and in contact with 
the bed.  Gastrocnemius scans will be taken with hip and knee flexed so that the foot 
is in contact flat with the bed.  These methods have been used in our previous 
study(7) and have been cited in other work(45). Diaphragmatic ultrasound will 
include diaphragmatic thickness, Diaphragmatic Thickening Fraction (DTF) and 
diaphragmatic excursion on both sides according to standard procedures. 
Muscle biopsies will be taken percutaneously under local anaesthetic, on days 1 and 
14 only. 
After the initial samples have been taken, the patient will be randomised using a 
computer-generated randomisation system, to receive either FES plus cycling or 
standard physiotherapy.  A computer-based block randomization system will be 
generated using R (randomizeR: An R Package for the Assessment and 
Implementation of Randomization in Clinical Trials). Allocation concealment will be 

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guaranteed by management of the randomization table by an external company not 
involved in the conduct of the study (MoRe Data GmbH, Giessen, Germany). 
Patients receiving FES plus cycling will receive 30 minutes of FES cycling on 5 days 
per week.  Other studies have applied between 20 -50 minutes of this exercise.  The 
device to be used is the Restorative Therapies (RT) 300 Supine with FES system, 
plus a 12 channel SAGE stimulator (Restorative Therapies Ltd, Baltimore, Maryland, 
USA). Surface electrodes will be placed on the quadriceps, hamstrings and calf 
muscles of both legs, with an additional electrode placed across the rectus 
abdominis muscle.  The aim of the electrical stimulation is to produce visible 
contractions in each muscle group, without causing pain.  If a contraction cannot be 
seen, treatment will continue, but with regular palpation of the muscle groups to feel 
for contraction.  This will be done every 5 minutes throughout the intervention period.  
In line with eStimCycle study, a maximum current of 140mA, pulse duration of 250-
500 microseconds, frequency of 40 Hz and pedal cadence of 30-45 revolutions per 
minute will applied. The intervention will be performed within 24h after consent has 
been obtained and will be classified as study day 1. Study day 1 has to occur within 
72 hours of intubation.  Patients will receive the intervention on 5 days per week.  
There will be one cycling device on the Intensive care Unit, which can be used for 6-
8 cycling sessions per day. Hence a total of up to 16 patients can be included at any 
given time point (6-8 patients in the interventional arm, 6-8 patients in the control 
group). 
Patients will be fully monitored during the study, with standard ICU equipment, 
including electrocardiogram, heart rate, arterial blood pressure, end-tidal carbon 
dioxide tension and haemoglobin oxygen saturation.  Heart rate variability will also 

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be measured using a skin sensor device (Isansys Lifecare Ltd, Abingdon, 
Oxfordshire, UK).  
All patients randomised to the intervention arm will have cycling sessions with FES 
for 14 days.  They will receive 5 sessions per week, and so should receive 10 
sessions over a two week period.  Should the patient be liberated from mechanical 
ventilation, they will carry on receiving cycling with FES until day 14.  In the unlikely 
event that they cannot tolerate FES once extubated, the intervention will be stopped. 
Based on discussions with the manufacturer, we expect that less than 10% of 
patients would be unable to tolerate FES whilst extubated, however, we wish to 
confirm this statement as part of this pilot trial to inform future studies.. 
All patients, regardless of intubation status, will have no further sessions of FES after 
day 14.  No further ultrasound scans, blood or urine tests will be conducted after day 
14.   
Ultrasound scans performed on day 14 will serve as the main comparator to baseline 
investigation.. In patients who failed to tolerate the intervention, ultrasound 
measurements will give an opportunity to assess if muscle is lost whilst not receiving 
FES, but still critically ill. 
Patients with a tracheostomy allocated to intervention will also receive FES with 
cycling until day 14. 
On day 14, in patients that are awake and suitably co-operative, assessment of 
strength using both hand grip dynamometry and the MRC Sum power score will be 
conducted by blinded physiotherapists.  
 

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Follow up testing will occur at 3 months post hospital discharge.  This will include: 
• Ultrasound of the 4 heads of the quadriceps and gastrocnemius muscles. 
• Ultrasound of the diaphragm muscles. 
• Performance of balance and gait testing using an electronic pressure 
detecting plate. 
• Performance of a 6-minute walk test. 
• MRC sum power test 
• Handgrip strength using portable dynamometry 
• Assessment of quality of life, using the SF-36 scale - The SF-36 questionnaire 
is commonly used for follow-up in research studies involving critically ill 
patients and is routinely used in our follow-up clinics, to which patients are 
invited to attend 3 months after ITU discharge. If patients are not available to 
attend the follow-up clinics, an attempt will be made to obtain the SF-36 
information via telephone interview. Patients will have the opportunity to 
decline participation. 
There will be no procedure for breaking the codes for randomisation, as the study 
team and the patient cannot be blinded to the treatment allocation. 
 
Patient end-points 
A patient will be removed from the study if: 
• 
A relative withdraws consent on behalf of the participant. 
• The patient, after regaining capacity, withdraws consent. 

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• There is difficulty in complying with treatment with more than two treatment 
sessions per week being missed (e.g. due to haemodynamic instability). 
Criteria for a patient to not receive a cycling session are in line with the 
CYCLE trial15. 
Data to be collected 
• Muscle cross sectional area, muscle thickness, muscle fascicle length, 
pennation angle and echogenicity in the vastus lateralis and medial head of 
gastrocnemius, change in muscle thickness and echogenicity of the rectus 
abdominus, diaphragm and change in cross sectional area of the rectus 
femoris and the three vastus muscles.  These will be measured on days, 1, 3, 
5, 7, 10, and 14. 
• Relationship between changes in muscle thickness and expression of blood 
and muscle inflammatory markers. 
• Measures of balance and posture using a specialised balance board in 
patients who survive to discharge from ICU. This will be tested 3 months after 
hospital discharge. 
• Long term outcome measures, including ultrasound measurement of ALL 
muscle groups, and tests of balances and gait, re-testing of the MRC Sum 
Power Score, and 6-minute walk test.  Quality of life assessment will be 
conducted using the SF36 questionnaire.   
• Ultrasonographic changes in diaphragmatic thickness, DFT and 
diaphragmatic excursion 
• 
Incidence of delirium, as assessed by the CAM-ICU method.  

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• 
Data collected from routine monitoring, such as heart rate, heart rate 
variability, haemoglobin oxygen saturation and end tidal carbon dioxide 
tension. 
 
Other data collected 
To answer the secondary research questions, the following data will also be 
collected: 
• Age, sex, weight, height, and Body Mass Index (BMI) 
• Admission APACHE II, ICNARC and SOFA scores 
• 
Routine blood results, including full blood count, urea and electrolytes, liver 
function tests, clotting screen and arterial blood gases.  
• A daily diary of standard physiotherapy received, time taken, and treatment 
received. 
• A daily diary of FES and cycling, including time spent cycling. 
• 
Blood glucose measurements. 
• 
Total infusion volumes, including inotropes/vasopressors, insulin, sedative 
agents, intravenous fluids, nasogastric feed and total parenteral nutrition. 
• 
Documented evidence of delirium, as assessed by the CAM-ICU method. 
• Ventilator settings, including inspired oxygen concentration, and time to wean 
off mechanical ventilation. 
• Use of renal replacement therapy, mode of replacement and indication for 
replacement. 
• Microbiological samples for culture. 

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• A “safety log” of incidents and injuries sustained in the course of using FES 
with cycling. 
o Dislodgement of arterial lines, central lines, urinary catheter and 
endotracheal tubes. 
o Haemodynamic changes including changes in blood pressure or heart 
rate of more than 20% of baseline. 
o Falls 
o Other injury to staff or patients 
o Death 
• Dose of cardiovascularly active drugs (inotropes, anti-arrhythmics, 
vasopessors) 
 
Further laboratory studies 
As well as expression of cytokines and histones in both blood and muscle samples, 
muscle biopsies will be used to conduct single fibre contractility studies. Using the 
blood and muscle cytokine and histone levels, we can assess if contractility in these 
fibres is reduced in patients who have greater levels of inflammatory markers.  
Haematoxylin and eosin (H&E) staining will also be performed, to assess nuclei 
count, extra-cellular matrix production and muscle area. 
Blood samples will be analysed by ELISA for a panel of cytokines (including muscle 
specific cytokines, ‘myokines’) and biopsies will be subject to RNA-sequencing to 
allow analysis of genome differentially transcribed genes independently of bias.  Key 
members of differentially expressed gene pathways will be verified by qPCR and 
Western blots.  To investigate whether differentially expressed genes result from 

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change in cytokine abundance, we will simulate this system in vitro.  Cultured human 
muscle cells will be exposed to the observed differentially expressed cytokines and 
RNA-sequenced.  
All laboratory investigations on samples obtained in this trial are part of a different 
funding and research application. 
Statistical analysis 
In general, sample size calculations are not required for pilot studies. We chose to 
continue recruitment until 18 patients in each group have reached day 14 of the 
study. This design will allow us to calculate a realistic drop-out rate for future trials 
and thus assess feasibility. We will use the inclusion/exclusion criteria we anticipate 
using in follow-up trials. With 18 patients in each arm completing the study until day 
14, we anticipate that useful information about the feasibility, the safety and the 
changes in muscle thickness can be obtained.  
Although not the primary aim of this project, the results from this pilot study may be 
used to generate data for sample size calculations for larger follow-up trials.  
Our previous non-interventional study showed a 50% drop out between days 1 and 
10. Therefore, we anticipate recruitment of 36 patients per arm to achieve 
completion of the trial until day 14 in 18 patients. 
The following estimates were considered for drop-out: Loss of 14-day follow-up due 
to death (10%), discharge from Intensive Care or High-Dependency Units before day 
10 (10%), inability to tolerate the intervention (20%), decline to continue in the trial 
after regaining capacity (10%).  

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A detailed breakdown of all measurements preformed at different time points and the 
proposed statistical approach is listed in Appendix C.   
In all statistical analyses, a p-value of less than 0.05 will be considered statistically 
significant.  For multiple testing the Bonferroni-Holm correction will be applied. 
Blinding 
Due to the nature of the study, it is not possible to blind the participants or the 
investigators.  However, ultrasound images will be saved as numbered images, with 
no detail as to which group the images come from.  Measurement of muscle 
thickness will be measured on a computer rather than at the bedside with ultrasound 
machine, so that the measurements are performed blinded. 
2.2.9 Ethical considerations 
Considerations related to subject selection and recruitment have been described 
already. 
Blood samples and urine samples shall be taken from the patients indwelling 
arterial/central lines and urinary catheters.  Surplus blood samples from blood taken 
for routine clinical purposes will be collected daily from the Clinical Chemistry 
Department.  Should an arterial line or central line be unavailable, blood will be 
obtained from venepuncture, if possible as part of a daily routine venepuncture to 
minimise pain and infection risk. Urine sampling will be performed via an indwelling 
urinary catheter or via collection a urine sample at the bedside. 
Muscle biopsies taken percutaneously may cause pain, skin infection, muscle and fat 
infection and bleeding.  The risk of skin infection in one trial is 1in 800(46), and 
serious bleeding reported in 1 in 5000 cases(47). 

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End of study, dissemination and archiving 
The study is expected to start on August 1st, 2018.  The study is expected to run for 
2.5 years, ending on the 1st February 2021.  The recruitment period is expected to 
last 12-18 months with expected recruitment of 2 patients/week.  Data analys and 
final report will take 6 months. The suggested study period will allow a 3 month 
follow up appointment, within the 2.5 years. An interim analysis will take place after 
50 patients will have been recruited. 
The study will be ended early in the event that: 
- Inability to recruit patients within 3 months after opening the trial.  
- Serious adverse effects associated with the trial device 
- Decision of the Data management committee after interim analysis 
- The study sample is completed 
Data will be presented at local, national and international conferences, as well as for 
publication in journals.  Patients who took part in the study can have their results 
discussed at the 3 months follow up appointment, and will also be sent copies of any 
publication on request. 
After data analysis is completed, all study material will be archived using an 
approved archiving company, in this instance Manchester Retrievals. 
 
 
 
 

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Appendix A – Study Flow Diagram  
Recruitment,  randomisation and groups 
 
 
 
 
 
 
 
 
 
Notes: 
Patients may be extubated between day 1 and 14.  If they are, they will continue to 
receive FES with cycling whilst awake.  In the unlikely event that they cannot tolerate 
this, they will receive passive cycling without electrical stimulation until day 14. 
Even if a patient is still intubated by day 14, the intervention will stop at day 14. 
Follow up testing will occur at 3 months post hospital discharge. 
 
 
Biopsy – 
Day 14 

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 Time scale of investigations and interventions 
Procedure/Test Day 
0 
Day 
1 
Day 
3 
Day 
5. 
Day 
7 
Day 
10. 
Day 14   
F/U 
3/12 
Consent 
x 
 
 
 
 
 
 
 
Randomisation 
 
x 
 
 
 
 
 
 
Start 
Intervention 
 
x 
 
 
 
 
 
 
Urine 
 
x 
 
x 
 
x 
x 
 
Muscle biopsy 
 
x 
 
 
 
 
x 
 
Blood 
 
x 
 
x 
 
x 
x 
 
U/S 
 
x 
x 
x 
x 
x 
x 
x 
Functional 
testing 
 
 
 
 
 
 
 
x 
Balance Board 
 
 
 
 
 
 
 
x 
Psychological 
 
 
 
 
 
 
 
x 
Heart monitoring and haemoglobin oxygen saturations will take place during cycling 
sessions. 
Cycling will be daily, for 5 times per week. 
 
 

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Appendix B – The CYCLE Trial Exclusion Criteria 
A. Daily exemption criteria for in-bed cycling 
Cycling or physiotherapy (PT) sessions will not occur if any of the following 
conditions are present: 
1. An increase in vasopressor/inotrope of more than 25% within past 2 h 
2. Active myocardial ischaemia, or unstable/uncontrolled arrhythmia after discussion 
with the intensive care unit (ICU) team. 
3. Mean arterial pressure (MAP) <60 or >110 mm Hg or out of range for this patient 
within the past 2 hours. 
4. Heart rate <40 or >140 bpm within the past 2 hours. 
5. Persistent SpO2 <88% or out of range for this patient within the past 2 hours. 
6. Neuromuscular blocker within past 4 hours. 
7. Severe agitation (Richmond Agitation and Sedation Scale >2 (or equivalent)) 
within past 2 hours. 
8. Uncontrolled pain. 
9. Change in goals to palliative care. 
10. Team perception that in-bed cycling or therapy is not appropriate despite 
absence of above criteria (e.g., active major haemorrhage from any site, acute 
peritonitis, new incision or wound precluding cycling, new known/suspected muscle 
inflammation (e.g., rhabdomyolysis)). 
11. Patient or proxy refusal. 
 
B. Criteria to terminate in-bed cycling or routine PT 
Cycling or routine PT will stop if the following occurs: 
1. Concern for myocardial ischaemia or suspected new unstable/uncontrolled 
arrhythmia. 
2. Unplanned extubation 
3.  Physiotherapist perceives continuing cycling or routine PT is not appropriate, 
for example, 
4. Respiratory—sustained O2 desaturation <88%; marked ventilator 
dysynchrony. 

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5. Cardiovascular—sustained symptomatic bradycardia (<40 bpm), tachycardia 
(>140 bpm), hypotension (MAP <60 mm Hg) or hypertension (MAP >120 mm 
Hg). 
6. Catheter or tube dislodgement or severe patient agitation. 
7. ICU physician, patient or proxy requests termination of session. 
 
 
 
 
 
Appendix C – Proposed measurements and statistical test 
An overview of all measurements and planned statistical analysis is presented in the 
table below. A p-value of less than 0.05 will be considered statistically significant. 
 

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Appendix C – Proposed measurements and statistical test 
An overview of all measurements and planned statistical analysis is presented in the table below. A p-value of less than 0.05 will be 
considered statistically significant. 
Due to multiple comparisons, the Holm–Bonferroni method is used to control the group-wise error rate. 
In all cases, a p-value of <0.05 after  Holm–Bonferroni correction will be considered statistically significant. 
 
 

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Category
Measurement
Units
Time of measurement
Summary Measure
Hypothesis to be tested (H0-hypothesis)
Statistical Test
NOTES
Patient Demographics
Age
Years
On admission/consenting
Mean and SD
There is no difference between intervention
and control group
Unpaired t-test
Height
Metres
On admission/consenting
Mean and SD
There is no difference between intervention
and control group
Unpaired t-test
Weight
Kilograms
On admission/consenting
Mean and SD
There is no difference between intervention
and control group
Unpaired t-test
BMI
kg/m2
On admission/consenting
Mean and SD
There is no difference between intervention
and control group
Unpaired t-test
Sex
Count
On admission/consenting
Count and percentage of group
There is no difference between intervention
and control group
Chi-square test
APACHE II score
Arbitary Points
On admission/consenting
Mean and SD
There is no difference between intervention
and control group
Unpaired t-test
Primary Outcome Measure
(Vastus lateralis)
Muscle thickness
Centimetres
Day 10
Mean change in thickness (cm), SD
There is no difference between intervention
and control group
Unpaired t-test
Mean % change in thickness, SD
There is no difference between intervention
and control group
Unpaired t-test
Skew, kurtosis
The data are normally distributed
Shapiro-Wilk
Secondary outcome measures
Ultrasound
Fascicle pennation angle
Degrees
Day 1, 3, 5, 7 , 10, 14
Mean change in angle (degrees), SD
There is no difference between intervention
and control group
Repeated measure analysis
Mean % change in angle, SD
There is no difference between intervention
and control group
Repeated measure analysis
(Vastus lateralis, medial head of
gastrocnemius
Fascicle length
Centimetres
Day 1, 3, 5, 7 , 10, 14
Mean change in length (cm) , SD
There is no difference between intervention
and control group
Repeated measure analysis
(Derived by trigonometry)
Mean % change in length, SD
There is no difference between intervention
and control group
Repeated measure analysis
FL= Thickness / sin (Pennation Angle)
Medial head of gastrocnemius
Muscle thickness
Centimetres
Day 1, 3, 5, 7 , 10, 14
Mean change in thickness (cm), SD
There is no difference between intervention
and control group
Repeated measure analysis
Mean % change in thickness, SD
There is no difference between intervention
and control group
Repeated measure analysis
Rectus femoris, Vastus Lateralis
Cross sectional area
Square Centimetres
Day 1, 3, 5, 7 , 10, 14
Mean change in area (cm2), SD
There is no difference between intervention
and control group
Repeated measure analysis
Intermedius and Medialis
Mean % change in area, SD
There is no difference between intervention
and control group
Repeated measure analysis
Rectus Abdominis
Cross sectional area
Square Centimetres
Day 1, 3, 5, 7 , 10, 14
Mean change in area (cm2), SD
There is no difference between intervention
and control group
Repeated measure analysis
Mean % change in area, SD
There is no difference between intervention
and control group
Repeated measure analysis
Diaphragm
Thickness
Centimetres
Day 1, 3, 5, 7 , 10, 14
Mean change in thickness (cm), SD
There is no difference between intervention
and control group
Repeated measure analysis
Mean % change in thickness, SD
There is no difference between intervention
and control group
Repeated measure analysis
All muscles
Echogenicity
Arbitary, scale from 0-1
Day 1, 10.
Change in echogenicity, SD
There is no difference between intervention
and control group
Unpaired t-test
Diaphragm
Thickening Fraction
Percentage
Day 1, 3, 5, 7 , 10, 14
Mean change in Fraction (%) SD
There is no difference between intervention
and control group
Log rank test
Diaphragm
Maximal Excursion
Centimetres
Day 1, 3, 5, 7 , 10, 14
Mean change in excursion (cm), SD
There is no difference between intervention
and control group
Log rank test
Measures of correlation
Change in muscle thickness on day
10 related to age/weight/baseline
muscle thickness
Centimetres vs yrs/kg/cm
Losses by day 10
Correlation co-efficient, r.
There is no correlation between muscle
thickness on day 10 and
age/weight/baseline muscle thickness
betwen intervention and control group
Pearson's test
Biochemical testing
Muscle Biopsy
TBC
TBC
Day 1, Day 10
TBC
TBC
TBC
Blood/Urine
TBC
TBC
Day 1, 5, 7, 10
TBC
TBC
TBC
Follow up measures
Dynamometry
Hand grip
Newtons
At 3 months F/U appointment Mean difference in force (N), SD.
unpaired t-test
Dynamometry
Force, flexion at the knee
Newtons
At 3 months F/U appointment Mean difference in force (N), SD.
unpaired t-test
6 minute walk test
Distance covered
Metres
At 3 months F/U appointment Mean difference in distance (metres), SD
unpaired t-test
Ultrasound vastus lateralis
Muscle thickness
Centremeters
At 3 months F/U appointment Mean difference in thickness (cm), SD
unpaired t-test
SF-36 score
Score on questionniare
Arbitary points
At 3 months F/U appointment Mean difference in points, SD
unpaired t-test
Balance
Average Sway
At 3 months F/U appointment Mean difference in sway, SD
unpaired t-test
MRC Sum Power Score
Total Score
Arbitary - from 0-36 points
At 3 months F/U appointment Mean difference in score, SD
unpaired t-test
Other
Incidence of delirium
Count
Count and %
From days 1-14
Perecentage difference
Chi-square test / Fisher's exact test
Incidence of needing RRT
Count
Count and %
From days 1-14
Perecentage difference
Chi-square test / Fisher's exact test
Safety - tubes/lines pulled
Count
Count and %
From days 1-14
Perecentage difference
Chi-square test / Fisher's exact test

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