Rehabilitation program after injuries

Physical trauma or injury is defined as damage to the body caused by external forces e.g. accidents, hits, falls and other causes. Major trauma can potentially lead to prolonged hospitalization, impaired physical ability, loss of organs and long-term disability or even death. Not only physical impacts, but trauma can also largely disrupt mental health, social engagement and financial status. To achieve a full recovery after major trauma, a comprehensive rehabilitation remains important as the a key accelerator to increase patient’s independence and enhance physical function, allowing for a quick return to daily life and activity. A number of clinical evidence has affirmed that rehabilitation program after trauma helps minimizing complications and shortening length of hospital stay. Multidisciplinary team for rehabilitation after trauma consists of physical medicine and rehabilitation physician (known as physiatrist), physiotherapist, occupational therapist, psychologist and nurses highly specialized in trauma care and rehabilitation. Due to a wide variation in patient’s conditions, an individual evaluation and personalized rehabilitation program should be specifically designed for each patient to achieve the best possible outcomes while taking patient’s needs and relative’s concerns into account.

Rehabilitation Care After Injuries

Post-traumatic rehabilitation care aims to holistically restore patient’s multiple systems affected by traumatic injuries. Based upon severity and symptoms, rehabilitation care can be delivered during different phases, including:

1. Rehabilitation in critical care unit

Patients in critical conditions are at greater risks of developing serious complications e.g. ventilator-associated respiratory infections that impair lung function, acquired muscle weakness due to prolonged hospitalization and deep vein thrombosis (a blood clot forms in a vein located deep inside the body).  Rehabilitation goals during this critical phase are aimed at preventing these life-threatening complications and restoring patient’s independence as quick as possible. Rehabilitation program consists of:

• Chest physical therapy: Chest physical therapy or CPT is an airway clearance techniques to drain the lungs, including percussion (clapping), vibration, deep breathing, huffing and  coughing in the postural drainage position. Since chest physical therapy helps eliminate secretions, it decreases work of breathing and promotes the expansion of the lungs.
• Respiratory muscle training: Respiratory muscle training aims to improve the endurance and strength of the respiratory muscles through specific exercises.

2. Pain management

Apart from pain management medications, muscle pain or pain related to nervous system can be alleviated by several techniques of rehabilitation approach. These include:

• Breathing exercises and relaxation
• Electrical nerve stimulation for pain relief
• Warm or cold compress for muscle sores and muscle spasms
• Medical massage for pain relief and relaxation

3. Improving bed mobility and activity of daily life training

For stabilized patients, bed mobility exercises substantially improve the functions of multiple organs and facilitate recovery process. Under close supervision of physiotherapist, bed mobility training includes:

• Upper and lower extremity exercises e.g. lifting arms and legs
• Rolling onto the side
• Moving the upper trunk off the bed
• Changing sleeping positions

4. Movement enhancement

Once the patients are able to start moving, movement enhancing training inside the patient’s room should be promptly performed e.g. standing up, sitting and walking. After training, patients should be evaluated whether they could be further transferred from intensive care unit to regular wards.

5. Swallowing training

To ensure that patients are able to swallow foods properly, speech and occupational therapists assess patient’s swallow function and any condition related to swallowing. Swallowing training usually involves exercises specifically aimed at improving the ability to swallow and strengthening coordination of the muscles and nerves associated with swallowing. Since neurological conditions such as stroke and extubation after mechanical ventilation as well as a long-term nasogastric tube feeding can often result in weakening muscles used for swallowing, leading to impaired an ability to swallow, these swallowing exercises are thus essential to improve the contact and coordination between the different muscles used while swallowing

6. Cognitive training

Severe traumatic brain injuries or other critical illnesses comprise a heterogeneous group with varying complexity of deficits and impairments, affecting both physical and mental health. Cognitive impairments due to critical injuries are substantial sources of morbidity for affected individuals and their family members. Disturbances of cognition, understanding and memory are the most common neurocognitive consequences of critical illness at all levels of severity. After an evaluation, an individualized program for cognitive enhancement and training will be designed and conducted by occupational therapists.

Rehabilitation During Recovery

During recovery phase, patients are encouraged to exercise and conduct their daily tasks with an increased intensity. Under close supervision of physiatrists and physiotherapists, patient’s physical fitness evaluation will be monitored on daily basis. Appropriate exercises that enhance mobility e.g. walking, riding a bike and balance training should fit patient’s physical ability when planning a personalized rehabilitation program.

Discharge planning

While receiving treatment in the hospital, all necessary advices from multidisciplinary team will be given to the patients and relatives. Discharge education includes daily life instruction, lifestyle modification, nutritional suggestion and environmental adjustment before returning home.

Ergonomic design at home

Following critical conditions e.g. stroke, some of patient’s abilities are often compromised, therefore ergonomic adjustments at home are important aiming at regaining independence and facilitating daily life while enhancing performance and quality of life. Home ergonomics involves housing and apparatus rearrangement e.g. ensuring sufficient lighting, appropriate stairs or slopes and slip-resistant flooring for fall prevention.

The role of nutrition in recovery phase

Catabolism is the set of metabolic pathways that breaks down complex molecules into smaller units that release energy for the body to consume. Critical illness largely disrupts the catabolic pathways, potentially leading to life-threatening conditions induced by sepsis, severe trauma, burn or other types of tissue injury. The main catabolic response to critical illness is characterized by whole-body protein loss, mainly reflecting increased breakdown of muscle proteins and loss of lean body mass. A number of medical studies have indicated that severe burns result in a sustained inflammatory hypercatabolic response and patients usually lose their muscle mass up to 1 kg. per day. In other critical conditions, besides burns, patients experience a significant muscle loss in the first 7-10 days after injuries. An increased muscle breakdown leads to muscle weakness, fatigue, trouble moving arms and legs and breathing difficulties caused by impaired respiratory muscles. As a result, patient’s quality of life is significantly diminished. Timely and adequate nutrition support plays a major role in preventing muscle loss and improving overall outcomes while enhancing a full recovery process.

After receiving treatments in an intensive care unit, patients require an increased amount of energy and protein to optimize the muscle functions and prevent further muscle loss. Clinical studies have pointed out that energy required during recovery phase  is approximately 1.7 times higher than the resting period. Recently, the nutritional guidelines or advices in nutrition support during recovery phase after critical illness are inconclusive. However, as suggested by The Minnesota Starvation Study, daily requirement of energy is ranged 3,000 – 4,500 kcal and daily requirement of protein is 1.5 -2.5 g/kg. of body weight (after starvation in healthy candidates). In order to preserve and strengthen muscle mass, during recovery period patients should be able to regularly consume their energy and protein-enriched diets up to several months or years.

The Needs Of Energy, Protein And Nutrients For Patients During Recovery PeriodEnergy

Extreme catabolism and immobility in critically ill patients contribute to the loss of total body protein and body weight. Patients usually fail to regain weight immediately after being discharged from intensive care. Common causes often involve a decreased appetite, nausea or vomiting and constipation induced by certain medications. It is important to ensure that patients receive adequate energy for building up their muscles and increasing body weight during recovering period.

It was reported that after removing ventilators, critically ill patients could only take 700 kcal per day which is less than 50 percent of the total body needs. Due to certain diseases or compromised conditions, large numbers of patients might not be able to take solid foods, leading to inadequate energy supply. Nutrient-fortified meal replacement drinks are alternatives for these patients. Available on shelf, these supplementary products have been medically formulated with sufficient amount of nutrients, vitamins and minerals, equivalent to regular diets. A variety of meal replacement products e.g. Neo-Mune®, Glucerna® and Boost Optimum® can be chosen for patients with limited oral intake.

Protein

To meet basic nutritional requirements, the recommended daily amount for protein is 0.8 – 1.0 grams of protein per kilogram of body weight. However, recovering from critical injuries e.g. burns requires more calories and protein for facilitating would healing process and boosting up immune functions as well as accelerating muscle formation and bone healing rates. To recover after injuries, clinical guidelines suggest a daily intake of 1.5 – 2.5 grams of protein per kilogram of body weight. For instance, a 60-kg patient requires 90 – 150 grams of protein per day which is equivalent to the consumption of protein sources e.g. meat, fish and egg 25-40 tablespoons per day. In patients experiencing a decreased appetite, it is recommended to gradually take small portions of protein for each main meal and snacking. Protein-enriched diets are steamed fish, egg, baked chicken and yoghurt. For vegetarians or vegans, a large amount of protein can be derived from soybean. Nowadays, almond milk is a nutritious, low-calorie drink that becomes very popular. Nonetheless, it contains less protein compared to cow’s milk or soy milk.

Vitamin C and Zinc

Vitamin C plays a critical role in collagen formation. Studies have revealed that after burn there is an increased daily requirement of vitamin C which helps in dermal collagen synthesis and wound healing process. Sources containing high amount of vitamin C are citrus fruits e.g. strawberry and kiwi, baked potatoes, broccoli and  bell pepper.

Zinc is an essential micronutrient that regulates all processes in wound healing mechanism, ranging from membrane repair, oxidative stress, inflammation to fibrosis and scar formation. Foods high in zinc are meat, fish, duck meat, chicken meat, milk and dairy products. Zinc can be also found in whole grains, dried nuts, hard-shelled nuts and grains.

Vitamin D and Calcium

Vitamin D and calcium are crucial elements for promoting bone . Calcium helps build and maintain bone formation, while vitamin D optimizes intestinal calcium and phosphorus absorption for proper formation of the bone. Patients with fractures must be ensured that they receive adequate amount of vitamin D and calcium for bone healing process. Main sources of calcium are milk, yoghurt and calcium-fortified soy milk. Two glasses of semi-skimmed milk or skimmed milk provide sufficient calcium that the body needs daily.

In addition to calcium, vitamin D is also necessary for bone strengthening. Without vitamin D,  the bodies cannot effectively absorb calcium. Vitamin D can be obtained from the sunlight. Foods containing high vitamin D include milk and cod liver oil. Some types of yoghurt are fortified with vitamin D and nutritional facts can be noticed on the nutritional labels.

Fibers

After critical injury or surgery, patients are often prescribed pain medications. Constipation is a common side effect of pain medicines. This occurs more often if opioid drugs are used (opioid-induced constipation). Taking sufficient fibers and drinking enough water greatly help to alleviate constipation. However, certain types of laxative drugs might be additionally required if patients experience severe constipation. Sources of fibers are whole grains, fruits, vegetables, beans and grains. The recommended amount per day is 3-5 portions  (a portion of fruits is equivalent to 1 banana, 1 orange and 6-8 small pieces of ripe papaya). Daily amount of 4 to 6 cups of vegetables per day as part of a healthy eating pattern should be maintained. Prunes and prune juice are natural laxative agents that help preventing constipation (sufficient water intake must be also taken).

Adequate hydration

Dehydration can substantially lead to severe complications, such as seizures, swelling of the brain, organ failure, shock and coma. Causes of dehydration often involve diarrhea and vomiting as well as insufficient water intake. Signs and symptoms indicating dehydration include headache, nausea, dizziness or lightheadedness, fatigue and weakness. To avoid dehydration, it is highly recommended to drink water 8-10 glasses per day.

Burn Injuries

For burn injuries care, it is necessary to relieve the pain and heal the wound as quickly as possible. Bangkok Hospital’s Medevac Center and our experienced multi-disciplined medical staff – together with our modern equipment and technology – stands ready to care for our patients with burn injuries from the initial admission through to preventing complications from the wounds or reducing scaring, so that our patients can maintain their self-confidence.

Types Of Burn Injuries

Burns are classified into 3 categories, depending on how deeply and severely they penetrate the skin’s surface.

First-Degree Burn: This affects only the outer layers of skin (the epidermis). The burn site is red, sore and painful to being touch. The skin around the wound is intact and has no blisters. It can heal by itself, and the care is focused on preventing skin irritation. The wound exhibits reddish or darker colors which will fade away.

Second-Degree Burn: In this type of injury, the epidermis and part of the deeper layer of skin (the dermis) are affected. The patient feels severe burning pain around the wound. The burn site is blistered. If the skin in broken, red or pink deeper layers of the skin can be seen along with seeping lymph fluid.The wound is healed after the damaged skin has fallen off and is replaced by healthy cells. Caring for the second-degree burn involves regular cleaning of the wound. But if the injury is very deep, it is necessary to remove the damaged area so that the wound can heal quickly, preventing any infection. Proper care will reduce harm to thetissue and lessen the chance of problems due to scaring.

Third-Degree Burn: Both the epidermis and dermis layers are destroyed. The injuries may reach muscle and bone. The wound is dry and hard, while the blood vessels around the burn site are clogged. Healing is complete only after the damaged skin is replaced by new tissue membrane, which takes a longer time and may result in a thicken scar (keloid). The membrane could also pull the skin around the wound, causing disfigurement. It might be necessary to removed damaged tissue and graft the skin, to encourage speedy recovery. Caring for this type of injury is complex and should be handled by an experienced medical team.

Patients’ Concerns

1. They are anxious about treatment of the wound – soreness, burning pain.
2. They may worry that they might lose the damaged part of their bodies: e.g., hand, foot, finger, toe etc.
3. They are nervous about disfigurement, scar, or the look of the injury.
4. A common concern is the phycological effect. It is a very important problem for many patients.

Burn Injuries Treatment Process

The medical team will determine the severity, size and depth of the wound based critically on the injury. It is crucial that a specialized and experienced medical team performs all the necessary treatments, which consist of:

• Administering fluid to compensate for any loss of fluid outside of the blood vessels, and to prevent any infection of the wound. In case of an infection, it may become necessary to remove damaged tissue and perform skin-grafting. This also includes monitoring for any problem as well as swelling which may require timely surgery to reduce pressure on muscle compartments, in order to prevent complications that may lead to loss of organ.
• Administering high protein nutrition to encourage immunity for speedy healing. In cases where patients need to be on ventilation machines, this will help them recover more quickly and, thus, reduces mortality rate.

However, the first 1 – 2 weeks are extremely critical. Proper treatment and care of burn injuries will lessen the possibility of any additional problem.

Technology Involved In Burn Injury Surgery

The technology applied in the surgery on patients with burn injuries helps quicken recovery and reduce scaring. This includes:

• Hydrosurgery – This technique uses a small jet of highly pressurized water to remove damaged tissue. An advantage of this method is that the effects on undamaged tissues – especially at the hypodermis layer – are reduced which, consequently, will allow the wound to heal by itself; thus, lessen the need for skin-grafting.
• MEEK Micrograft – This method involves cutting and arranging the skin grafts in such a way that they can cover 4 to 9 times the donor site, allowing more area of the wound to be covered effectively as compared to the traditional approach.
• Wound Dressing – The type of bandage used has the special ability to destroy any bacteria while accelerating the skin growth, enabling the wound to heal more quickly. Bandaging includes silicone bandages, wound dressing gel, etc. In this case, it is necessary to have an experienced medical team to select the appropriate type of bandaging for each wound.

Our Services

Bangkok Hospital’s Medevac Center stands ready to take care of any burn injury – from the initial admission through to preventing scaring problems – with our experienced multi-disciplined medical team. We provide careful treatment plans that cover every facet of our patients’ burn injuries care – through our surgeons, infectious disease specialists, psychiatrists, rehabilitation doctors, nurses, physiotherapists, as well as anesthesiologists in cases where surgeries are required. For severe burn injuries, we are equipped to provide immediate care – such as providing fluid to help the patient recover from burn shock or kidney failure. Also, the healing process includes a regiment of nutrition and additional treatments – such as Hyperbaric Oxygen Therapy – all of which will help quicken the recovery and, at the same time, lessen mortality rate, reduce complications, minimize scaring and keloids. Post-treatment care involves close follow-ups, to ensure that each patient is healthy and can confidently return to normal life again.