Rehabilitation Guide

• weakness
• decreased mobility
• voice changes
• increased sputum
• swallowing difficulties
• skin sores/wounds
• fatigue
• strange memories/hallucinations
• hair loss/thinning
• feeling anxious/low in mood
• bladder and bowel dysfunction
• poor memory/concentration/problem solving
• poor appetite
• loss of role/job
• breathlessness.

What is fatigue?

Fatigue is a common symptom following critical illness. For most people, fatigue usually subsides within a few weeks, but for some it can persist longer. Fatigue is often felt to be both physical and mental tiredness and is said to be overwhelming:

• A feeling of having no energy, like you could spend the whole day in bed.

• Feeling breathless after only light activity.

• Difficulty sleeping.

• Feeling more emotional than normal.

• Having trouble thinking or making decisions.

The feeling of fatigue is often exacerbated by activity and can sometimes develop the following day, taking several days to improve.

Managing Fatigue

Planning, pacing and prioritising activities.

• delay or delegate tasks
• pacing helps to prevent peaks and troughs
• choose your best time of day for each activity
• goal setting helps you to focus
• concentrate on one activity at a time
• organisation - avoid unnecessary trips e.g. up and down stairs
• don't do all your tiring activities in one go
• break larger tasks down into smaller stages

The aim of energy conservation is to improve your quality of life, by conserving your energy for the activities you “like to do” as well as those you “have to do”, within a safe and well structured environment.

• Sit rather than stand when completing tasks
• Listen to your body – rest before you feel exhausted
• Allow time to complete an activity without rushing
• Use adaptive equipment to save energy
• Keep frequently used items in easy reach
• Ask others for help.

Grading activity involves looking at the things we do in every-day life and breaking them down into achievable steps which can be adjusted as able.

People often associate the concept of energy with batteries and describe that having fatigue makes them feel like they have an empty battery, reporting that even on the ‘good’ days their energy levels are still significantly lower than prior to their illness.

Pacing and grading activity rations energy and uses it to best effect. The intention is to avoid flattening the battery and allow opportunities for energy levels to rise. Pacing uses smaller amounts of energy at one time and spreads the total energy used out over longer periods.

• Stop speaking and moving, give yourself time to recover your breath.

• Choose a position which will make it easier for you to breathe.

• Use breathing control techniques.

• Gradually try to make your breaths slower and deeper.

• Find a distraction – it may help to focus on a picture, or view from a window.

Step 1: Positions to ease breathlessness

• The following positions support the muscles in the body that help us with breathing.

• Try to relax your hands, wrists, shoulders, neck and jaw as much as possible.

Make sure you are fully over on your side. Resting your upper arm on a pillow may also help. Relax down onto the pillows as much as possible. Having your legs apart may also help.

Experiment with your arm position – find what is comfortable with you. When sitting, sit upright, have your legs uncrossed and keep your head up. Leaning forward will also help.

Step 2: Breathing techniques

• The aim is to move from fast, upper chest breathing to relaxed, slow tummy breathing. You may find it helpful to rest your hand on your tummy as you do this, feel it rise and fall gently with each breath.

• Remember 3 Rs: Rise the tummy as you breathe in, Relax the breath out, Rest and wait for the next breath to come.

Breathing Rectangle

• Follow the sides of the rectangle with your eyes as you breathe in (nose) and out (pursed lips).

• Gradually slow the speed your eyes move around the edge of the shape to slow your breathing.

Practice these techniques regularly so they will feel more natural to use when you are breathless.

Pursed lip breathing

• Breathe in gently through your nose.

• Breathe out with your lips pursed as if you are whistling.

• Try to blow out as long as comfortable, do not force your lungs to empty.

Blow as you go

• Breathe in before you make the effort.

• Breathe out whilst making the effort (e.g. as you lift an object).

• Always breathe out on the hardest part of the action.

Active Cycle of Breathing Technique (ACBT)

The Active Cycle of Breathing Technique is a set of breathing exercises that can be used to help you clear sputum from your chest.

Coughing alone can be tiring and ineffective, so the ACBT is designed to:

• Loosen and clear sputum.

• Help you breathe more easily.

• Improve the efficiency of your cough.

• Reduce the risk of chest infection.

You can use this method of breathing in whatever position you find comfortable or seems to clear the most sputum. Make sure the position you use is comfortable and has your head, neck and arms well supported, with your shoulders relaxed down. Your physiotherapist may advise you of specific positions to try.

Another effective way of clearing sputum is engaging in activity – this will be guided by your physiotherapist.

Stages of active cycle of breathing

• Breathing control
• Deep breathing (3-4 breaths)
• Breathing control
• Deep breathing (3-4 breaths)
• Breathing control
• 2 or 3 huffs
• Cough (if needed).

Breathing Control

Breathing control is the part of the cycle to allow you to rest and relax your airways between the deep breathing and huffing. Breathing control can also help when you are short of breath, anxious or in a panic.

Refer to the instructions above in “breathing techniques” on how to perform this.

Deep Breathing

Exercises Deep breathing is used to get the air in your lungs behind the secretions stuck in your small airways.

Take a long, slow, deep breath in, through your nose if comfortable, if not through your mouth. Breathe out gently and slowly through your mouth. Some people find it helpful to hold their breath for two or three seconds at the end of each breath in, before breathing out or to ‘sniff’ air in through your nose quickly at the end of the deep breath in.

Once you have completed the deep breathing exercises, go back to breathing control again to ensure your airways are relaxed.

Huffing

Huffing helps to move sputum up your airways by making it ‘rattle’.

• Take a medium sized breath in.

• Breathe out quickly with your mouth wide open, as though you are steaming up a mirror. Your tummy muscles should tighten when ‘huffing’.

• Repeat two-three times with breathing control in between each huff. If you are wheezing with each huff you may be huffing too hard or for too long.

Return to the start of the cycle and begin again if your lungs do not feel clear of sputum. Ensure you rest when you have completed three to four cycles before beginning again.

• Transfer from bed to chair
• March on the spot
• Mobilise around the bed space
• Wash myself sat in a chair
• Manage feelings of panic
• Read one chapter of a book

Some people who have been critically unwell may experience difficulties with eating, drinking, and swallowing. This could be due to your underlying condition, altered taste, reduced appetite, breathlessness and fatigue, muscle weakness, or, for some people, the need to be intubated whilst in intensive care. You may have managed to eat and drink whilst in hospital or you may have required a feeding tube. If you do not use your swallowing muscles for a while, they may become weaker and may make eating and drinking become more difficult.

You may have been seen by a speech and language therapist (SLT) in hospital who may have given advice on how to modify your diet/fluids or provided strategies to make swallowing easier.

If you notice any of the following symptoms, please contact your GP who can refer you to the relevant team for further support:

• Coughing or choking when eating or drinking

• A wet, gurgly voice quality after swallowing

• A sticking sensation in the throat when eating and drinking

• Frequent chest infections

Strategies that may make eating, drinking and swallowing easier include:

• Making sure you are sat fully upright when eating and drinking

• Not eating or drinking if you’re feeling extremely tired or breathless. Rest, and return to eating and drinking later

• Taking your time when eating and drinking. A ‘little and often’ approach may help

• Taking smaller sips or bites

• Opting for foods that do not need to be chewed as much, if you are becoming tired/breathless when chewing

• Avoiding talking when you are eating and drinking, as this can open up your airway and food can go down the wrong way

Looking after your mouth

Sometimes, individuals can experience a very dry mouth, with cracked and sore lips, particularly when in hospital. This is especially the case if an oxygen mask is needed. It is important to keep your mouth moist and clean to prevent bacteria building up and causing infections.

Make sure you:

• Brush your teeth or dentures, twice daily, using toothpaste and remember to remove your dentures overnight.

• Drink plenty of fluids (water is best).

• Use a lip balm to keep lips moist and prevent cracking.

Communication refers to speech, voice and language. Following critical illness you may experience changes to your communication.

This may be as a result of your underlying condition or the treatment and equipment used to help you get better. Talking can be more difficult if you are breathless and your voice might sound weak, quiet, rough or hoarse. You may have a sore throat if you have been coughing a lot or if you needed a breathing tube during your hospital admission.

A good breath is very important in helping us to speak in a clear voice that can be easily heard and understood by others. You may feel that your voice is weak and your speech is not as clear as it used to be. This should improve as your symptoms resolve.

Here are some strategies of how to look after your voice and use clear speech:

• Sit in an upright position and take a breath before talking.

• Speak in shorter sentences and take regular breaths to avoid straining at the end of sentences.

• Reduce background noise when communicating with others.

• Avoid shouting or forcing your voice out. It is better to use your voice without straining, even if it means it is quiet and breathy.

• Do not whisper.

• Avoid throat clearing. Try clearing your throat by swallowing instead.

• Stay hydrated by drinking plenty of water.

• Reduce caffeine and alcohol intake.

• If your voice feels tired, stop, rest and try later.

On rare occasions the voice does not improve without treatment and a referral to Ear, Nose and Throat (ENT) and Speech and Language Therapy (SLT) may be necessary. This can be arranged by your GP.

Symptoms should resolve as you recover but if you are experiencing difficulties with understanding other people’s speech, forming your own sentences, producing clear speech or voice, then a Speech and Language Therapist (SLT) will assess this and support you to manage or rehabilitate these difficulties. Speak to your GP who can refer you onto your local Speech and Language Therapy team.

Following a balanced diet will help to ensure your body receives all the nutrients it needs to recover. The eatwell guide can be used as a guide to what a balanced diet is. 

Fruit and vegetables

Fruit and vegetables are a good source of vitamins, minerals and fibre. They will help to support your immune system. Aim for 5 portions of fruit and vegetables each day and choose items that are a variety of different colours, to make sure you get a range of different vitamins and minerals. You can choose fresh, tinned, frozen or dried fruit and vegetables, they all count towards your 5 a day. Consider taking a multivitamin and mineral supplement if you are struggling to manage your 5 a day.

Starchy foods

Starchy foods such as bread, rice, potatoes, cereals and pasta are a good source of energy. They provide energy, fibre, calcium and B vitamins. Choosing wholemeal versions of these foods will increase your intake of fibre which, along with drinking plenty of fluid can help treat constipation.

High protein foods

These foods are an important part of a balanced diet, particularly if you have been unwell. They provide energy, vitamins and minerals and play an important role in improving muscle function and wound healing. Foods such as meat, fish, pulses, beans, lentils and meat alternatives such as soya protein are included in this group. You may wish to have a high protein food or drink following any exercise you do, this can help to build muscle and strength. Ways to increase your protein intake are discussed later in this leaflet.

Dairy or dairy alternatives

Milk, cheese, yogurts and fromage frais (creamy, soft cheese) are a good source of energy, vitamins and calcium. There is no evidence that milky products increase the production of, or thickness of, mucus and therefore they can safely be included in your diet as you recover from critical illness.

Poor appetite and weight loss

You may have lost weight whilst you have been unwell, or be continuing to do so, or have a poor appetite. It is common for people to lose weight during periods of illness. When you are critically ill it is common to lose significant amounts of muscle mass. It is also common to have increased energy needs following both critical illness and a respiratory illness. You may find you need to consume more energy and protein than you previously did to maintain your nutritional status. You may also find your appetite has reduced or you cannot manage the same portion sizes as before. The sections below provide advice about fortifying your diet. Please contact your GP or dietitian for more advice if you are struggling to eat or with your weight.

Tips to help with poor appetite and weight loss:

• Eating ‘little and often’ throughout the day, 5-6 smaller meals or 3 smaller meals with 3 high energy, high protein snacks in between (see below).

• Eating a ‘fortified diet’ which means adding extra energy and proteins to your food with significantly increasing the amount (see protein ‘toppers’, ‘fortified milk’ and adding increasing energy intake below).

• Drinking higher energy drinks, such as ‘fortified milk’, milkshakes with ice-cream and smoothies with full fat yoghurt.

Increasing protein intake

• Try to include a portion of meat, fish, beans, soya protein or cheese at each meal. • Include higher protein snacks between meals or desserts such as milky puddings, yogurts, custards, cheese or nuts

• Use a high protein food ‘topper’ on your meals such as; - Cheese sprinkled on baked beans or potatoes - Crushed nuts added to porridge, cereals or desserts - High protein yogurt added to cereals or fruit

• Use ‘fortified milk’ in your cooking, on cereals and in your drinks. To make fortified milk; add 4 heaped tablespoons of skimmed milk powder to a small amount of milk and mix to a paste then whisk into a pint of milk or watch this video: https://www.youtube.com/watch?v=f7lMqS4Z7io

• Include milky drinks between your meals such as making your coffee with warm fortified milk rather than water Increasing energy intake • Avoid low fat products, choose the full fat alternatives.

• Add extra honey, jam, syrup or dried fruit to your cereal

• Add butter, cream or cheese to potatoes and vegetables

• Spread bread with thick butter and mayonnaise for sandwiches

• Include snacks between meals such as crisps, chocolate, yogurts, cheese and biscuits, dried fruit and milky drinks

• Add cream to soups (can be tinned or home made)

Eating when you are short of breath

Eating can be more difficult when you are short of breath.

• Eat smaller portions of meals and include snacks frequently between meals.

• Choose softer, moist foods that are easier to chew and swallow

• Add extra gravy, sauce or mayonnaise to meals.

• Take your time with meals.

• Prepare meals in advance in bulk if possible to allow time to rest after making meals before eating.

• Try to plan your meals for the times of the day you are less breathless.

• Sit upright when eating try to avoid slouching or lying down whilst eating

If you are experiencing taste changes:

It is common for people to experience a change in taste after critical illness. Taste changes differ from a bland taste, to a sweet, salty or metallic taste. For most, taste changes will get better over time. The following may help:

• Regular sips of fluid throughout the day

• Rinsing your mouth with water before and after meals

• Maintaining good oral hygiene and brushing twice daily

• Trying stronger flavours if you are lacking taste

• Avoid having sweeter foods if you have a sweet taste and opt for savoury flavours

Avoid having salty food if you have a salty taste and try something sweet

• Using plastic cutlery if you are suffering from a metallic taste

References and more detailed information:

British Dietetic Association (BDA). (2020). Nutrition at home after critical illness. Retrieved from here.

Vitamin D

During the winter months (from around October to March) and when recovering from illness you may not get enough time outside to produce enough vitamin D from the sunlight. Consider taking a vitamin D supplement – in the UK a supplement of 10 micrograms (400 IU) a day is recommended.

Tips for getting the food you need

Feeling unwell and recovering from critical illness can make it more difficult to go shopping for and cook the foods you need.

• Use ready meals, take-aways and food delivery services.

• Use supermarkets online delivery services.

• Ask friends and family to get you some items when they are out doing their shopping.

• Have a good supply of store cupboard ingredients you can use to make meals such as baked beans, tinned fruit and vegetables, pasta and sauces, tinned soup, tinned fish, tinned puddings and custard.

• You may be eligible for priority supermarket deliveries. Visit the gov.uk website here for more information about who qualifies and how to register.

• Local food banks are active to help those in need. Contact The Trussel Trust on 01722 580180 or go to their website for information on how to access your local food bank.

• Blackpool Teaching Hospitals Dietetics Service – 01253 956777 and bfwh.askadietician@nhs.net.

Please consider contacting your GP or dietitian for more advice if you are struggling to eat or with your weight or if you have a medical condition such as diabetes, kidney disease or high cholesterol.

• Feeling anxious or worried, fearful, angry, depressed or low in mood

• Physical difficulties such as physical changes common to anxiety and stress:
- shaking and trembling
- tension and muscular aches
- sleep disturbance
- tiredness
- lack of energy
- poor concentration or forgetfulness
- palpitations
- shallow or rapid breathing
- dizziness
- feeling nauseous, vomiting, or diarrhoea.

Emotional and physical changes can feel scary and unpleasant. But be assured that these changes are often our body’s normal responses to the stress and shock, having been through a significant or lifethreatening situation. There are no rights or wrongs here, everyone is different.

Most people after these traumatic events will be shaken, but most over time emerge emotionally unscathed. All reactions are individual and not everyone experiences feelings that are described here. The important thing is to acknowledge that you have been through a difficult time and experiencing any emotional responses to this is normal.

Sometimes, people feel they are reliving traumatic events through nightmares and flashbacks after the event has passed, and this can lead to feelings of isolation, irritability and guilt. They may also have problems sleeping and find concentrating difficult. Although these are normal experiences after a traumatic event, if you are still having difficulties about 6 weeks after the event, or if these experiences are particularly troublesome, you should seek advice from your GP. There are some strategies listed below which can help with nightmares and flashbacks, particularly grounding exercises and creating a safe space.

Try to respond kindly and compassionately to yourself, noticing your frustration, disappointment and allowing time to come to terms with what you have been through. It can help to monitor your symptoms initially to see whether they improve or get worse without treatment.

Talking about your worries:

Talking to others can help you to come to terms with the experiences you have had, but sometimes there are restrictions on how you might be able to do this face to face. There are resources available and access to talk to others who might understand some of how you are feeling, although your experience is unique to you and your circumstances and you should not judge your recovery against others.

Talk to your family, friends and your usual social support network, but if this is not available or you prefer to talk to someone outside of your circle, there are services available which are listed at the end of this document.

Taking care of yourself:

Avoid unhelpful ways of coping: such as drug and alcohol use, sleeping all day, isolating yourself from friends and family, neglecting self-care; and do not over or under exercise (see advice for physical rehabilitation guide).

Sleep: It can take time for your normal sleeping and waking cycles to return after being in hospital. Below are some helpful sleep hygiene tips:

• Avoid caffeine later in the day.

• Try to avoid sleeping for long periods during the day.

• Avoid screen time e.g. T.V, smart phones, and tablets before bed.

• Create an a.m. and p.m. routine which signals your body wake or rest.

• Try to expose yourself to natural light during the day if possible – this can help establish your natural circadian rhythm.

• Create a calming and comfortable sleeping environment – aim to keep the temperature at around 18 degrees.

• Reading or listening to relaxing sounds or music may help you fall asleep. You may find sleep apps helpful (see relaxation section).

Eating and drinking: (see Nutrition guide).

Staying connected: It is important to stay connected with family and friends during your recovery. In the case that face-to-face contact isn’t an option ensure to use other mediums of communication such as phone or video calls.

Grounding strategies: Grounding your mind to focus on the here and now is important, especially as we sometimes forget that we are safe in the present. Some people find it helpful to write a grounding statement to remind themselves that they are safe. You can read it if you become upset, such as “I survived and I am safe now”. You can try anything which you find works, from relaxed breathing, visual imagery or yoga to rubbing a lotion into your hands, anything which keeps you in the present moment. Alternatively, you can keep a mental inventory of the world around you i.e., list all the colours/patterns you see, the sounds you hear, and the scents you smell or something you like to taste.

The best strategies are those where you focus on your five senses – what you can see, hear, smell, touch, taste. You may need to do some trial and error to find what works for you.

Creating a safe space: This can be a real place which you can go to or a place you imagine in your mind where you feel safe. It’s important that this place is easily accessible. You can fill this place with things which bring you comfort, real or imaginary, for example a warm blanket, happy photos or a scented candle.

Other ways of taking care of yourself:

Activities: what did you used to enjoy at home? – Start to pick up some manageable activities that give you a sense of relaxation, pleasure and achievement. Remember to be gentle with yourself and set realistic goals.

Resilience: Think about specific challenges you have faced in the past – how do these experiences help in this situation?

• Consider useful advice you received from others

• Who was supportive or helpful at the time?

• What did you say to yourself?

• Could anything you did to help you cope in the past be helpful now?

• What did you learn about how to cope with challenges?

• How did you get through it? • What did you do that was most helpful?

• What did you do to be compassionate with yourself?

Anxiety: Feelings of tension and anxiety are normal experiences following difficult or life threatening experiences. Anxiety can make you experience physical feelings which may be new to you, including:

• fluttering chest – palpitations

• racing heartbeat

• breathlessness

• “butterflies” in stomach

• shaking

• feeling more sensitive to surroundings

• dry mouth

These feelings are normal and will pass. They are the body’s automatic response to physical danger so we are ready to fight, run or freeze. This is ideal if there are physical dangers around, but can feel scary and over-warranted when the trigger for anxiety is not something we can fight or run away from such as worry and memories of difficult situation.

Mindfulness and relaxation: Mindfulness and relaxation can help to reduce physical symptoms of anxiety and the intensity of our thoughts. Regular practice is necessary to experience the full benefits of the strategies. It is normal to have experiences of worry or stress. Dwelling on what might have been or what might happen in the future can be a natural response, but not necessarily very useful or helpful. Where possible try to focus on what is in your control. What you can do and what you are able to achieve. The more we worry about thoughts and feelings we are having, the worse they are likely to get. 

• lack of sleep

• loss of routine

• dehydration

• poor appetite

• infection It is important to rest, remain hydrated and have good nutritional intake.

Severe confusion – delirium – is usually temporary and resolves as illness improves, but can take a while to clear and feels scary for the person experiencing it and their families or carers.

“Delirium” is most commonly experienced by people who have been in ICU or have needed breathing machines in hospital. If the onset of new severe confusion is experienced at home please seek medical attention. This may be a sign that something else is going on in the body.

Delirium is sometimes obvious to others, called hyperactive delirium. Patients may become very agitated or even aggressive because of the frightening things they are experiencing and can be very restless. However, delirium is sometimes hard to notice, and this is called hypoactive delirium. It might not be obvious that the patient is having frightening thoughts. They may appear to be very still and quiet and withdrawn from others.

Causes of delirium: a number of factors affect the way the brain works which cause delirium including:

• Infection
• High temperature
• Low oxygen levels
• Constipation
• Medicines given to treat illness including sedatives
• Severe pain
• Loss day/ night routine in an unfamiliar environment
• Dark, noisy hospital wards.

People affected by COVID-19:

We are still learning about the additional challenges during COVID-19, but some of these additional factors could include: witnessing staff in PPE, challenges in communicating, social isolation – loved ones prohibited from visiting, lack of daylight due to changes of wards during COVID, and witnessing other patients on ventilators/critical illness. If you have any concerns please contact your G.P to discuss these.

What are the signs of delirium?

People may see or hear things which are not there but seem very real to them – called hallucinations. They can be frightening, especially when realising that other people haven’t shared their experiences. This can cause feelings of isolation and fear. People with delirium cannot think clearly or pay attention and can struggle to understand what is going on around them.

For example a person might:

• not know who they are

• think they can see a frightening object, people or animals

• think they have been kidnapped or are in danger

• think people are trying to harm them, including staff

• believe noises are threatening and signs of danger

• feel agitated and struggle to concentrate

• behave in a way which is not usual for them.

Delirium can change quickly so there may be periods when someone is able to join in a conversation with those around them one moment and then lapse into a confused state again in the next. Delirium is temporary, but can take a while to completely clear. It is important to remember that full recovery can take time and people continue to feel distressed by their experiences, or memory of them, for a longer period.

An increase in anxiety and concentration and memory problems may be noticed, or perhaps someone may be bothered by disturbing images or dreams of delirious experiences.

Some symptoms can continue following discharge from hospital There may be some continuation of difficulties such as:

• confusion

• difficulties remembering things

• emotional changes

• disturbances to sleep pattern

• changes to usual behaviour

• feeling drowsy

• feeling agitated.

What helps recovery from delirium?

There are no right or wrong ways to react and everyone is different. Human beings are very resilient and most will process what has happened and find ways through these experiences without lasting emotional effects.

Delirium is temporary and feelings will resolve, however, some ways to help manage and process them are:

• Talking to others about your feelings and emotions can help make sense of how you are feeling

• Writing down what you can remember from your hospital admission, hearing the timeline that people tell you; and reading diaries that have been kept may help you collect your memories.

• When ready and if feels safe to do so, you may choose to arrange to revisit the hospital. This may be difficult, but is one way to make sense of what was real and imaginary.

Some people may not want to remember and may not want to talk about it, whereas others may find it very painful to remember and may need to take their time before they can begin to think about what has happened. It is important that you do what feels helpful to you.

Once discharged from hospital, you will be invited back for a follow-up clinic appointment. This is a clinic run by a specialist critical care team who may have cared for you during your stay on the unit. It provides the opportunity for patients to discuss their recovery and verbalise any concerns, physical or psychological.

Patients find this helps make sense of their time on the unit and organise the memories they have of this time. The team will provide support and may signpost to other services if appropriate including Psychology. As mentioned earlier, it may also be possible to arrange a visit back to the unit to help make sense of your experiences.

What if you feel things are not improving?

If you continue to experience difficulties that are persistent or become overwhelming, it is important to seek advice from your GP or local mental health crisis team.

Breathlessness can make us feel anxious, which in turn can add to our breathlessness. The following relaxation exercises can help:

• Visualise a relaxing scene, such as a favourite place, a walk, a garden, the beach or somewhere from your imagination that makes your feel happy and secure (not places that evoke bad or sad memories). Imagine what you can see, hear, feel and smell.

• Body scan: Scan your body from head to toe, trying to release any tension in your muscles.

• Let go of thoughts: Imagine you are sitting on a riverbank watching leaves drifting downstream. When a thought or feeling comes into your mind, try to see this as a leaf and let it drift away from you, and disappear.

• Velindre App: This is a free App to download, use the relaxation exercises section.

• Relaxed Melodies App: This is a free App where you can choose your favourite relaxing sounds.