Occupational therapy rehabilitation after your stay in intensive care

This leaflet explains how we can help you recover and return to your everyday activities following time in intensive care (ICU). If you have further questions, please speak to the therapist or nurse caring for you.

Recovery after time spent in ICU

Everyone reacts to a stay in ICU in different ways, but most people undergo some reaction, both during and afterwards.

It is common for people to have health problems that remain after they have experienced critical illness. These problems can involve your body or mind (thoughts, feelings) and they may affect your family.

There can be problems with thinking and judgment, known as cognitive (brain) dysfunction, or other mental health problems. There can also be ICU-associated muscle weakness.

You may need help with activities after leaving the hospital. Up to 50% of patients may return to work within the first year, but some might not be able to return to the jobs they had before their illness.

ICU-associated muscle weakness

Muscle weakness often develops during an ICU stay. It is a common problem associated with being critically ill and it affects

• 33% of all patients on ventilators
• 50% of all patients admitted with severe infection (known as sepsis)
• up to 50% of patients who stay in the ICU for at least a week.

Patients with muscle weakness may take more than a year to recover fully. It makes daily living activities difficult, for example grooming, dressing, feeding, bathing and walking. It may greatly delay you from resuming activities the way you used to before you were ill.

How to manage fatigue and muscle weakness

Pace	Sit to wash your face, brush your teeth and dry your hair Have a rest after each Pat yourself dry rather than rubbing dry
Plan	Keep all the things you need in the same place Put a mirror at face level when sitting Liquid soap lathers more quickly than bar soap Use long-handled equipment, such as a long-handled sponge
Prioritise	Try using dry shampo Use electric items, such as a toothbrush and razor

Pace	Allow plenty of time and take a rest as you go Sit in the shower if possible
Plan	Open an inside door to allow good ventilation Use long-handled equipment Equipment such as a rail or chair can help you get in and out of the bath or shower
Prioritise	Is bathing an activity you enjoy and are willing to spend a lot of energy on? Is a daily bath or shower necessary? Can you have a strip wash at the sink instead during your early recovery?

Pace	Sit to dress Break up tiring tasks with easy ones and take a rest several times Dress your lower half first, when you have the most energy
Plan	Keep all the things you need in the same place Collect all your clothes before you start Wear clothes that fasten at the front and are loose Put pants and trousers on at the same time and then pull them up together Put skirts on over your head Sit down to put on shoes and socks. Lift and cross one leg onto your knee to bring your foot closer
Prioritise	Can you rearrange your wardrobe and drawers so that all your clothes are close together?Can a member of your household get your clothes out and help you get dressed?

Pace	Put on the sheet, stop for a rest, then do the pillowcases, then rest again Sit for some of the task, such as doing the pillows Get help with the duvet cover
Plan	Have your bed positioned so you can walk all the way around it Start and finish one side, then move to the other so you only circle the bed once
Prioritise	Can you take turns with someone you live with, or can they make the bed for you?

Pace	Spread the preparation throughout the day Peel vegetables in the morning, cook in the afternoon and reheat in the evening Sit to prepare food or when waiting to stir Take rests during and after cooking
Plan	Cook large amounts and refrigerate or freeze extra portions Get everything you need ready before you start Find recipes with a short preparation time Use a trolley to move cooking equipment or cutlery for the table
Prioritise	Buy frozen ready meals for days when you are very tired Can a member of your household cook for you?

Pace	Have a rest when you get to the shop Take your time collecting your items Put heavy items in different bags Use a trolley to push your shopping home rather than carrying a bag
Plan	Make a list that follows the aisles and means you only need to visit one or two shops Shop at quieter times of the day Avoid large/deep trolleys to reduce bending when putting in and removing items Pack items together that go in the fridge/freezer or same cupboard, so it is easier to unpack
Prioritise	Can a member of your family help? Can you do online shopping?

Pace	Spread the tasks throughout the day Load the machine in the morning and empty it in the afternoon Sit down to iron Use a low clothes horse and sit to hang out washing Take rests during and afterwards
Plan	Wear clothes that wash, dry and iron easily Do several smaller loads each week, rather than one large wash Store everything you need in one place, such as powder and pegs Use a laundry basket on wheels If possible, have your dryer at chest height
Prioritise	Is it necessary to iron all of your clothes? Can someone help you fold large or heavy items, such as sheets and towels? Can someone else do the laundry?

Pace	Spread heavy activities throughout the week For example, Hoover a different room each day Do a mix of heavy and light activities in a day Have a rest during and between activities Sit down for tasks like polishing or washing up
Plan	Collect all the items you need before you start Use long-handled equipment where possible Use a mop to clean floor spills rather than bending over Allow washing-up to air dry Use small rubbish bags so you don’t have to lift one heavy bag
Prioritise	Can someone else do the heavy activities for you?

Hand-strengthening exercises

You can do these gentle exercises with putty to get your hands moving again after your stay in hospital.

For each of the following exercises, follow the instructions 5 times (this equals one set of exercises). Do each set three times. (This means you will squeeze the putty 15 times for each exercise).

Resisted lateral pinch exercise Place the putty in between your thumb and the side of your index (first) finger. Press down with your thumb to squeeze the putty. Unflatten the putty, reposition it and start again.
Resisted single finger extension exercise Put the flattened putty and the heel of your hand on the table. Begin with your index (first) finger bent into your palm while keeping the finger tip on the putty. Straighten your finger against the resistance of the putty. Do not let your wrist or forearm help with the motion of your finger. Lift your finger out of the putty. Reflatten the putty, reposition your hand and start again.
Resisted three point pinch exercise Hold the putty inbetween the pad of your thumb, index (first) and middle fingers. Pinch the putty as firmly as you can, by squeezing your fingers and thumb together. Unflatten the putty, reposition your hand and start again.
Resisted thumb extension exercise Use your unaffected hand to wrap the putty around your thumb. Hold the end of the putty in your unaffected hand. Move your thumb out from the palm of the hand. Re-roll the putty, reposition it and start again.
Resisted thumb flexion (bending around joint) exercise Place the putty in your palm. Bend your thumb towards the base of your little finger, pushing it into the putty. Unflatten the putty, reposition it and start again.
Resisted thumb palmar abduction (moving thumb) exercise Wrap the putty around your thumb and index (first) finger. Move your thumb away from the index finger so it is in front of your palm. Unflatten the putty, reposition it and start again.
Resisted two point pinch exercise Place the putty between the pad of your thumb and the pad of your index (first) finger. Squeeze the putty. Unflatten the putty, reposition it and start again. For variation, you can change the thickness of the putty between your thumb and finger.

Hand-movement exercises around the house

When your hands are feeling strong enough, you can start doing some common daily-living movements. These include:

• picking up coins and small items such as paper clips, pasta pieces
• buttoning and unbuttoning clothes
• tying shoelaces
• handwriting exercises from a section of a newspaper, book or magazine
• shuffling and passing during card games
• opening household items such as jars, bottles, cans
• engaging in hobbies such as painting, playing a musical instrument, jigsaw puzzles, arts and crafts.

Cognitive or brain dysfunction

This refers to problems connected with remembering, paying attention, solving problems, and organizing or working on complex tasks.

After leaving the ICU, 30% to 80% of patients can experience these kinds of problems. Some people improve during the first year after discharge from the hospital, but other people may never fully recover.

Cognitive dysfunction might affect whether you can return to work or perform daily tasks that involve organization and concentration.

How to manage memory and concentration difficulties

Create a food shopping list or a to-do list.
Save medical appointments and other important dates in a calendar.
Do regular crossword, sudoku or word search puzzles.

Other mental health problems

Critically ill patients may develop problems with falling or staying asleep. They may have nightmares and unwanted memories. Reminders of their illness may produce intense feelings or strong, clear images in their mind. Their reactions to these feelings may be physical or emotional.

Patients may also feel depressed and anxious and have symptoms of post-traumatic stress disorder (PTSD). These include having bad dreams and unsettling memories, feeling ‘keyed up’ and wanting to avoid thinking or talking about their stay in the ICU.

How to manage anxiety

Go for a walk	Meditate
Eat healthily	Prioritise sleep

Progressive muscle relaxation

The idea behind progressive muscle relaxation is that your body may not know the difference between being tense and relaxed. This makes it hard for you to relax properly.

It will help if you can learn how to tense up and then release.

The following exercise can teach your body how to tense and release:

• lie comfortably on the floor, your bed, or any other available surface
• tense your toes and hold for 5 seconds
• relax your toes and hold for 30 seconds
• moving up your body, tense your foot and hold for 5 seconds
• relax your foot and hold for 30 seconds
• tense your calves and hold for 5 seconds
• relax your calves and hold for 30 seconds
• repeat tensing and relaxing with each part of your body, moving upward and finishing with your head and neck. If you prefer, you can reverse this and begin with your head, working your way down to your toes.

More information

Society of Critical Care Medicine on PICS www.sccm.org/MyICUCare/THRIVE/Post-intensive-Care-Syndrome
Royal College of Occupational Therapists on how to conserve your energy www.rcot.co.uk/conserving-energy
Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center on PICS www.icudelirium.org/patients-and-families/pics
Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center on cognitive impairment www.icudelirium.org/patients-and-families/cognitive-impairment

_{Images by Freepik (incl rwapixel, studio4art, upkiyak, macrovector, pikusperstar and brgfx)
Exercise content reproduced by kind permission of TrackActive Pro: Exercise Prescription Software with Outcome Measures} 

Contacts

Maria Paula Alvarez, Intensive Care Unit Lead Occupational Therapist, Monday to Friday 8 am to 4 pm

020 8546 7711 bleep 765