After ICU your rehabilitation programme by yud11183

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After ICU: your rehabilitation programme
Introduction
The aim of this booklet is to provide you with a rehabilitation programme to increase your
stamina, muscle strength and suppleness following your period of critical illness.
The exercises should be performed daily over a 12-week period, starting from the time
when you get home. While doing physical activity, we want you to rate your perception of
exertion using the Modified Borg Scale (next page) and to record the time you spend
exercising each day in the Exercise Diary (pages 9-10).


Why do we need to exercise?
− Increases the heart function
− Aids weight reduction
− Increases energy levels
− Increases muscle strength and bone density
− Increases suppleness, posture and co-ordination
− Helps reduce stress
− Long term, it reduces blood pressure and resting heart rate.


When not to exercise
− If you are feeling ill or have a temperature
− If you have not warmed up properly
− If you have just eaten a big meal
− If you have chest pain or any unexplained symptoms
− If it is very hot, cold or windy.


Where to exercise
− At home – make sure you have adequate space to move your body freely and that
  there are no obstacles that you could trip over or bump into.
− At local facilities, such as sports centre or an exercise class. However, make sure that
  the trainer/supervisor is aware of any health problems and do not exert yourself.


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Rehabilitation after a critical illness

Modified Borg Scale: rating of perceived exertion
Perceived exertion is asking “how hard does the exercise feel to me?” and rating it on a
scale of 1-10 with 10 being the hardest. You should aim to work between level 3 and level
5 on the scale equal to 60-85% of your maximum heart rate. This level will provide
cardiovascular exercise and improve your fitness. Build up gradually and work to a level
that is right for you!


Rating 1
During:          Easy, effortless, comfortable breathing, no strain.
After:           No aches or pains, comfortable.
Day after:       Rested, could repeat the exercise easily.

Rating 2
During:          Mild effort, deeper breathing, can feel muscles.
After:           Quick recovery (2-5 mins), no aches or pains, comfortable.
Day after:       Rested, could repeat the exercise easily.

Rating 3
During:         Harder breathing, slight sweat, muscles working and heart rate strong.
After:          Short recovery (4-7 mins), comfortable.
Day after:      Comfortable, no aches or pains.

Rating 4
During:         Slightly breathless (but able to talk), sweating, muscles working.
After:          Short recovery (5-8 mins), comfortable.
Day after:      Comfortable, no aches or pains.

Rating 5
During:         Breathless but not speechless, sweating, working hard, heart beating stronger.
After:          Short recovery (5-10 mins), comfortable, alert, invigorated.
Day after:      Not tired, feeling of well being.

Rating 6
During:         Very breathless, speechless, uncomfortable, tight chest, nausea.
After:          Long recovery (more than 10 mins), tense muscles, palpitations, dizziness.
Day after:      Exhausted, depressed, pain, nausea.

Rating 7+ is reaching your maximum heart rate. It is not advisable to work at this as it is
pushing too hard. Rate 10 is the strongest exercise you will ever feel – pushing yourself to
the limits. Doing this can give rise to unnecessary symptoms and is of no further benefit
than Rating 3-5. Remember, start at Rating 1 and gradually build up towards Rating
3-5 – don’t overdo it!

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Rehabilitation after a critical illness

How can I be sure that I’m working at Rating 3-5?
If you think you are working too hard at the exercises, you can slow down your rating and
make the exercises easier by:
− Reducing the repeat times
− Reducing the distance between your legs.
There are lots of ways of altering exercises to suit individuals. If you have bad knees or
stiff shoulders or a back problem, the exercise can be changed so that you do not
aggravate the problem. However, only you know how you feel when you are exercising
and by using the Borg Scale on the previous page, you will know that you are working at
the right level. Always ask advice if you are not sure about anything or if you don’t like a
particular exercise.


Warm up/Cool down exercises
− Always warm up for 10 minutes before exercising, this gradually increases your heart
  rate and warms up your muscles, which reduces the risk of injury. It also prepares your
  mind for exercise.
− These exercises include those that are pulse raising and mobility exercises to prepare
  your muscles and joints for exercise.
− Always cool down for 10 minutes after exercise. This stretches the muscles to avoid
  injury and returns your heart rate to normal.
− Wear suitable clothing – comfortable clothing that allows you to move freely, e.g. t-shirt,
  shorts or jogging bottoms. Shoes should be non-slip and provide support for your foot,
  e.g. trainers.
− Keep a bottle of water with you when you exercise and drink water regularly to avoid
  dehydration.
− Aim to work at easier level for warming up and cooling down (Borg Scale)
Reference: Borg G A (1982) Psychophysical bases of perceived exertion. Med. Sci Sports
Exerc 14: 377-381


Exercises
You are advised to try and incorporate 30-40 minutes of exercise on each day of the week.
The following exercises include:
− Warming up
− Strengthening
− Balance
− Cardiovascular, and
− Cooling down.

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Rehabilitation after a critical illness

Warm up and Cool down
Choose either to walk or run on the spot and then follow the general stretching exercises.
You should be aiming to exercise gently at this stage.
                                   Standing…                           Standing…
                                   march on the spot                   jog on the spot
                                   or




                                   1. Slowly make large                Sitting…
                                      circles backward                 turn your head to
                                      with your arms.                  one side until you
                                   2. Change direction                 feel a stretch. Hold
                                      and now begin                    for approximately 5
                                      making forward                   seconds. Repeat to
                                      circles.                         the other side.
                                   3. Repeat slowly in
                                      each direction.

                                   Lying on your back                  Stand in a walking
                                   with your knees                     position with the leg
                                   together and bent…                  to be stretched
                                   slowly roll your knees              straight behind you
                                   from side to side,                  and the other leg
                                   keeping your upper                  bent in front of you.
                                   body still.                         Use the support of
                                                                       a chair or wall.
                                                                       Lean your body
                                                                       forwards and down
                                                                       until you feel the
                                                                       stretching in the calf
                                                                       of the straight leg.
                                                                       Hold for
                                                                       approximately 30
                                                                       seconds, then relax.
                                                                       Swap legs and
                                                                       stretch the other leg
                                                                       in the same way


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Rehabilitation after a critical illness

Strengthening exercises
You should start with the Stage 1 exercises and choose the number of repetitions that will
enable you to work at the correct level of the Borg Scale.
As a guide, think about the maximum number of repetitions you think you can manage and
subtract two.
Once an exercise becomes too easy, you can progress to Stage 2 of that exercise.
This may mean that you might be doing some exercises at Stage 1 and some at Stage 2.
Remember that each line of the exercise represents a different muscle group, so some
may be easier than others, depending on your recovery and your muscle strength prior to
your ICU stay.


Muscle strength exercises
Stage 1                                                Stage 2
                                Lying on your back                    Lying on your back
                                with knees bent…                      with arms crossed
                                flatten the small of                  on your chest…
                                your back into the                    tighten your
                                floor by squeezing                    stomach muscles
                                your stomach                          and lift your head
                                muscles gently.                       and shoulders off
                                                                      the floor.
                                Stand straight,                       Lying on your back
                                holding on to chair…                  with knees bent…
                                bring your leg                        squeeze your
                                backwards keeping                     buttocks together
                                the knee straight.                    and lift your bottom
                                Do not lean                           off the floor. Return
                                forwards.                             to starting position.

                                Sitting on chair…                     Stand straight with
                                pull your toes up,                    feet apart and
                                tighten your thigh                    pointing forwards…
                                muscle and                            slowly bend your
                                straighten your                       knees and then
                                knee. Hold                            return to starting
                                approximately 5                       position.
                                seconds and slowly
                                relax your leg.




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Rehabilitation after a critical illness

Muscle strength exercises (continued)
Stage 1                                                 Stage 2
                                Lying on your back…               Lying on your
                                bring your leg to the             side…
                                side and then back                Keep the leg on the
                                to mid position.                  floor bent and the
                                                                  upper leg straight.
                                                                  Lift the upper leg
                                                                  straight up with
                                                                  ankle flexed.
                                Stand facing a wall               Crawling position…
                                with arms straight                do push ups.
                                and hands on wall.                Remember to keep
                                Do push ups against               your neck straight
                                wall, keeping body                and your chin
                                in a straight line.               tucked in.
                                To make the
                                exercise easier,
                                stand closer to wall.
                                To make more
                                difficult, move feet
                                further away from
                                wall.




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Rehabilitation after a critical illness

Balance exercises
Try to gradually increase the time you can hold these exercises
To start with, you may only be able to hold the position for a few seconds. You are looking
to be able to increase this to a few minutes, if possible.
You should find that the exercises gradually get harder. Choose exercises 1, 2, 3 and 4 to
begin with. Exercises 5 and 6 are advanced exercises that you can complete once you
achieve exercise 4.


Balance exercises
                                   Crawling position…                  Crawling position…
                                   lean forward                        lift your right leg
                                   transferring your                   straight back and
                                   weight on the arms,                 then bring it back to
                                   then backwards and                  start position. Swap
                                   to sides.                           legs and do same
                                                                       with other side.
                                   Standing…                           Standing…
                                   walk with one foot in               lift one leg, using a
                                   front of the other as               wall for support.
                                   though you were
                                   walking on a
                                   tightrope.


                                   Standing…                           Standing on one
                                   lift one leg off the                leg…
                                   ground and keep                     pass a ball under
                                   your balance.                       one knee.
                                   To progress, lift your
                                   arm straight forward,
                                   then lift your knee on
                                   the same side of your
                                   body. Keep your
                                   balance.




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Rehabilitation after a critical illness

Cardiovascular exercises
You should start with Stage 1 exercises and gradually progress to Stage 2.
You should be aiming for a total of 30-40 minutes of moderate intensity physical activity on
each day of the week.
The cardiovascular exercises can be used with the warm up and cool down exercises to
make up your 30-40 minutes.


Cardiovascular exercises
Stage 1                                            Stage 2
                            Sitting in a chair…                        Sitting with your
                            lift your leg up off                       arms crossed…
                            the seat, keeping                          stand up and then
                            the knee bent.                             sit down slowly on a
                            Return to starting                         chair (this can be
                            position.                                  made easier/harder
                                                                       by changing height
                                                                       of chair).
                            Standing…                                  Go for short walks
                            march on the spot.                         several times a day.
                                                                       Gradually increase
                                                                       the time or distance
                                                                       you are walking.




                            Standing…                                  Standing…
                            walk up and down                           jog on the spot.
                            the stairs.                                Gradually increase
                                                                       the time you are
                                                                       able to do this.




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Rehabilitation after a critical illness

Rehabilitation Programme exercise diary
The exercises aim to increase your stamina, muscle strength and suppleness and should
be performed daily over a 12-week period. Please score 3 things each day:
1. The total time spent exercising.
2. Your perception of your exertion, using the Modified Borg Scale.
3. The level of exercises you undertook.


Week 1: Date:             Day 1           Day 2   Day 3   Day 4   Day 5   Day 6   Day 7
Minutes exercised
Borg Scale score
Level 1 or Level 2


Week 2: Date:             Day 1           Day 2   Day 3   Day 4   Day 5   Day 6   Day 7
Minutes exercised
Borg Scale score
Level 1 or Level 2


Week 3: Date:             Day 1           Day 2   Day 3   Day 4   Day 5   Day 6   Day 7
Minutes exercised
Borg Scale score
Level 1 or Level 2


Week 4: Date:             Day 1           Day 2   Day 3   Day 4   Day 5   Day 6   Day 7
Minutes exercised
Borg Scale score
Level 1 or Level 2


Week 5: Date:             Day 1           Day 2   Day 3   Day 4   Day 5   Day 6   Day 7
Minutes exercised
Borg Scale score
Level 1 or Level 2


Week 6: Date:             Day 1           Day 2   Day 3   Day 4   Day 5   Day 6   Day 7
Minutes exercised
Borg Scale score
Level 1 or Level 2


Week 7: Date:             Day 1           Day 2   Day 3   Day 4   Day 5   Day 6   Day 7
Minutes exercised
Borg Scale score
Level 1 or Level 2




Rehabilitation after a critical illness                                                   9
Rehabilitation after a critical illness

Rehabilitation Programme exercise diary (continued)
Week 8: Date:             Day 1           Day 2   Day 3   Day 4   Day 5   Day 6   Day 7
Minutes exercised
Borg Scale score
Level 1 or Level 2


Week 9: Date:             Day 1           Day 2   Day 3   Day 4   Day 5   Day 6   Day 7
Minutes exercised
Borg Scale score
Level 1 or Level 2


Week 10: Date:            Day 1           Day 2   Day 3   Day 4   Day 5   Day 6   Day 7
Minutes exercised
Borg Scale score
Level 1 or Level 2


Week 11: Date:            Day 1           Day 2   Day 3   Day 4   Day 5   Day 6   Day 7
Minutes exercised
Borg Scale score
Level 1 or Level 2


Week 12: Date:            Day 1           Day 2   Day 3   Day 4   Day 5   Day 6   Day 7
Minutes exercised
Borg Scale score
Level 1 or Level 2




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Rehabilitation after a critical illness

Notes
Please use this page to record any questions or concerns you may have to ask at clinic.




Rehabilitation after a critical illness                                                   11
Rehabilitation after a critical illness




Royal Berkshire NHS Foundation Trust
Royal Berkshire Hospital
London Road
Reading RG1 5AN
www.royalberkshire.nhs.uk



Illustrations courtesy of Physio Tools Ltd and The Saunders Group Inc.


Produced by: ICU, January 2010
Review due: January 2011



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