Rehabilitation: Types, Indications, Guidelines, and Therapies

Introduction

Recovery after critical illness takes time. This rehabilitation program aims to improve the patient’s quality of life and restore it to its previous state. Physical, mental, economic, social, and psychological factors affect the survivors of critical illness and their caretakers(family). Rehabilitation therapy helps to improve the patient’s quality of life after discharge from the hospital or intensive care.

What Is Rehabilitation?

Rehabilitation is a part of the recovery process. It promotes good health and helps adults to be independent to do their daily activities. Rehabilitation therapy differs for every individual according to their specific impairments and health conditions. A multidisciplinary team(MDT) carries out the rehabilitation process for the individuals. The MDT includes:

• Physician.

• Rehabilitation doctors.

• Rehabilitation nurses.

• Clinical psychologists.

• Dietitian.

• Physiotherapists.

• Occupational therapists.

• Speech and language therapists.

The MDT team is not limited. It assigns specialists for a particular disease and patient’s needs.

What Are the Types of Rehabilitation?

The four types of rehabilitation are:

1. Preventative rehabilitation.

2. Restorative rehabilitation.

3. Supportive rehabilitation.

4. Palliative rehabilitation.

What Are the Sequelae of Critical Illness That Require Rehabilitation?

The adults recovering from critical illness may have many physical and non-physical difficulties after the critical illness, which require rehabilitation.

1) Physical Sequelae

• Pain.

• Feeling tired all the time.

• Reduced oxygen intake.

• Decreased mobility.

• Inability to do daily activities independently.

• Disuse atrophy(reduced size and strength of the muscles if not used enough).

• Myopathy(skeletal muscle disorder causing muscle weakness).

• Anorexia(reduced or loss of appetite).

• Malnutrition.

• Dysphagia(difficulty in swallowing).

• Ossification(soft tissues become calcified and hardened).

• Change in voice.

2) Non-Physical Sequelae

• Irritability.

• Anxiety.

• Delirium.

• Stress.

• Depression.

• Difficulty in concentration.

• Insomnia(sleep disorder).

• Post-traumatic stress disorder(PTSD).

What Are NICE Guidelines for Rehabilitation After Critical Illness?

National Institute for Health and Care Excellence(NICE) recommended guidelines for rehabilitation after critical illness in adults in march 2009. According to the NICE guidelines, the patients discharged from critical care are reviewed for 2 to 3 months. The service providers should assess and review the patient’s health. Face-to-face assessment is conducted either in the hospital or in the community. Service providers identify the problems and arrange patient support or equipment if needed.

Skilled healthcare professionals who know patients’ critical problems and rehabilitation care pathways conduct rehabilitation assessments or questionnaires. They reassess the health of the patients. The clinical commissioning group conducts follow-ups. The contact details of the healthcare professionals are provided to the patients at the time of discharge for follow-up.

After assessment of the patients, they are referred to the appropriate specialist or rehabilitation provider if:

• The recovery rate of the patients is slower than expected.

• Any physical or non-physical morbidity developed which were not present earlier.

• Rule out post-traumatic stress disorder (PTSD).

• Check for post-intensive care syndrome (PICS).

What Is Post-Intensive Care Syndrome?

Patients admitted to the intensive care unit are at increased risk of developing post-intensive care syndrome. They develop cognitive symptoms such as poor memory, difficulty concentrating, anxiety, and depression. This syndrome occurs due to intense treatment methods, equipment, and side effects of sedatives and painkillers.

The healthcare team manages PICS by:

• Lowering the dose of sedation and painkillers.

• Medications and psychological and behavioral therapies to treat stress.

• Patients are advised to get adequate rest, eat healthily and exercise.

What Are the Rehabilitation Therapies Used After Critical Illness?

People undergo rehabilitation to recover from critical illness difficulties or sequelae.

Inpatient Rehabilitation: It remains unclear, and patients are discharged a few days after surgery. It is better to opt for an inpatient stay and rehabilitation for patients without caretakers.

Outpatient Rehabilitation: It is also called day rehab. The multi-disciplinary team delivers this program focussing on individual needs. The outpatient rehabilitation environments include the following programs:

1. Strength and Reconditioning -This helps people confined to the bed(bedridden) continuously for an extended period to get back on their feet and walk.

2. Joint Groups - The main goal of this group is to help people who have undergone arthroplasty surgeries improve their strength, balance, and movements of the joints.

3. Back Care Group - This helps people to strengthen their back and reduce pain in the back. The people in this group suggest exercise to strengthen back muscles and bones.

4. Falls Prevention Program - This program lasts 6 to 8 weeks. It includes simple modifications of the home of old-aged patients to reduce the risk of falls. This program is for people at higher risk of falling. It recommends physical exercises.

5. Cardiac Rehabilitation - This program is to help patients with heart problems such as heart failure, heart attack, heart transplantation, heart valve repair, and angina. The program aims to reduce future risks. The specialists in the rehab team provide training for exercises and counseling for stress and recommend lifestyle changes to lower elevated blood pressure, high cholesterol, stress, and diabetes.

6. Neurorehabilitation - This program targets patients with neurological problems such as brain injury, stroke, demyelination, etc. It is a multi-disciplinary approach that helps to relearn the skills lost due to brain damage.

7. Oncology Rehabilitation - The main aim of this program is to help patients stay active and reduce the side effects of chemotherapy. The oncology physical therapists work with cancer survivors. The program supports the patient in overcoming physical, mobility, and cognitive problems.

8. Pulmonary Rehabilitation - This program helps people with chronic breathing problems such as chronic obstructive pulmonary disease(COPD), sarcoidosis, pulmonary fibrosis, cystic fibrosis, and emphysema. The program helps the patients with breathing strategies to avoid breathing difficulties.

9. Burn Rehabilitation - Burn rehabilitation starts from the first day of the injury and continues even after scar formation. The program aims to prevent deformity, pressure sores, edema, contractures, and stiffness.

10. Educating patients about the use of prostheses after amputation of legs.

All the rehabilitation programs have the following factors in common:

• Education.

• Physical exercises.

• Psychosocial support.

Conclusion

It is better to start the rehabilitation process as early as possible. The rehabilitation process is initiated during the critical care stay and continues for 2 to 3 months after critical care discharge. The rehabilitation program should be made available to everyone who needs it. It should be affordable and high in quality. Rehabilitation is not globally spread due to a lack of funds, resources, and limited trained rehabilitation professionals.