Personalised Nutrition Plans

Individual responses to nutritional therapy can vary based on factors like the severity of the deficiency, underlying medical conditions, and genetic variations^{4, 5}.

A personalised and holistic approach to nutrition in neurorehabilitation is essential to address the unique needs of each patient. Capacity can be altered after brain injury and therefore specific capacity assessments regarding nutrition should be performed⁶.

Tailored meal plans should be produced for those who do not have capacity. For example, those caring for a diabetic patient who lacks capacity will need strict guidance on carbohydrate portions and suitable snacks.

Effective communication and collaboration between dietitians, neurologists, physiotherapists, and other healthcare providers are essential for implementing comprehensive and coordinated care plans⁷.

Long term rehabilitation care can often pose difficulties such as patients becoming low in mood and reporting that their only solace is found in high fat, high sugar foods.

Many patients in neurorehabilitation have previously been addicted to drugs and/or alcohol, and find that they replace these substances with high fat, high sugar foods. Dietitians should gain regular feedback from patients regarding their preferences of meals on the menu, and work closely alongside the catering team to produce seasonal menus. Those creating menus must comply with the British Dietetic Association (BDA) nutrition standards⁸.

Rotational menus are important to help prevent menu fatigue and therefore improve nutritional intake. Dietitians should also ensure that low fat, low sugar snacks are readily available on the wards/units where residents have access to the kitchens.

In addition to adequate protein for muscle maintenance, patients should be supported to achieve at least 700mg of calcium per day alongside adequate protein intake to aid optimal bone mass density and sarcopenia; this will support long term mobility goals and aid optimisation of rehabilitation⁹.

Those with capacity and functional ability should be supported with functional kitchen skills by the occupational therapist. The dietitian can support these sessions by providing appropriate recipes for meals and snacks, and participating with cooking with patients in a therapeutic nature.

Monitoring of patient’s weight, hand-grip strength, food intake and bowel movements can indicate how successful dietetic care plans have been during a given review period.

At discharge, patients should be offered physical activity and health promotion, and follow-up services to ensure that the benefits of neurorehabilitation are achieved and maintained¹⁰.

Dysphagia

Brain injury and dysphagia are inextricably linked. Brain injuries can directly damage the brainstem and cerebral cortex, areas responsible for coordinating swallowing movements^{11, 12}. Cognitive impairments like poor attention, decreased muscle control, and sensory deficits can disrupt the complex sequence of swallowing stages¹².

Dysphagia of course impacts quality of life and can interfere with a patient’s desire to participate in therapeutic mealtimes. For example, a patient may require a bib due to their dexterity, meaning that feeding themselves can be messy. They may find it embarrassing to eat in front of other patients, so may want to avoid meal times.

Transdisciplinary working between dietitians in speech and language therapists is essential for comprehensive rehabilitation, along with ongoing support to ensure safe and satisfying mealtimes. The dietitian should be present at some meal times so they can liaise with the occupational therapist to identify if patients require adaptive cutlery, lipped plates and/or rubber plate mats.

Dietitians and speech and language therapists should work closely with the catering team to ensure that dysphagia training has been provided, such as ‘Dining With Dignity’¹³. This will instil kitchen staff with confidence to provide appropriate textures.

This training should also be provided to support staff so they understand the responsibilities all staff have to ensure patients receive food and drink that is modified to their prescribed texture.

When creating meal plans, it is important to take into consideration that brain injury patients experience fatigue throughout the day. Smaller, more frequent meals distributed throughout the day can improve nutritional intake and absorption.

Any pre-existing comorbidities such as inflammatory bowel disease, gastroparesis or irritable bowel syndrome need to be considered, as neurorehabilitation patients may not be able to communicate any gastrointestinal discomfort.

Bowel charts should be monitored by the dietitian frequently, considering whether patients require laxatives or pancreatic enzyme therapy such as Creon, if appropriate¹⁴.

Vitamin D

Vitamin D deficiency can be common following long hospital stays in the acute stage of brain injury, and patients are more at risk during rehabilitation due to lack of sunlight exposure¹⁵.

Although research on vitamin D for neurorehabilitation remains in the preliminary stages it has been identified as important; deficiencies have been associated with cognitive decline and impaired neurological function, as well as decreased muscle strength, balance and physical performance^{17, 18, 19}.

Vitamin D supplementation is also shown to have some neuroprotective properties²⁰. It stimulates the production of nerve growth factors, crucial for neuronal survival and regeneration, fostering the brain's rebuilding process and is consequently hypothesized to aid prevention of secondary brain injury²⁰.

Moreover, vitamin D facilitates calcium absorption, which is essential for maintaining neuronal health and signaling, and also pertinent in stroke survivors as they are more at risk of osteoporosis²¹. 

Despite these hypothesised benefits, data shows discordant results as some studies show a positive role in vitamin D for brain function, while others indicate adverse effects. A double-blinded randomised controlled trial found that 12 month vitamin D supplementation improved cognitive function in adults with mild cognitive impairment²². However it may not be possible to extrapolate the results to brain injured patients as the study did not specify whether the impairments were caused by injury.

Similarly, in a cohort of patients with traumatic brain injury, a significant improvement in recovery rate was found in a randomised controlled trial comparing a progesterone and vitamin D supplementation, as opposed to progesterone and placebo supplementation alone²³. However, more research investigating if this combination is effective is required²³.

Some studies indicate that vitamin D combination therapy with omega-3 fatty acids can reduce inflammation and limit the onset of secondary damage, however research is limited²⁴.

Although optimal doses of vitamin D for rehabilitation are yet to be identified, it is advisable that dietitians in neurorehab settings conduct medication audits to ensure vitamin D is prescribed for all patients in accordance with BDA guidance²⁴.

Medication audits will also identify patients on any psychiatric medication that could influence weight changes and subsequent dietetic care plans (Table 1)²⁵. 

Pressure Ulcers

Neurological disease patients present an increased risk of developing pressure sores and ulcers due to restricted mobility or impaired sensitivity ^{26, 27}. These sores can potentially contribute to additional complications such as infections, cellulitis, bone and joint infections, cancer, and sepsis²⁸.

Sensory deficits such as compromised sensation may prevent neurorehabilitation patients from feeling discomfort caused by prolonged pressure, delaying early detection and intervention of pressure sores²⁷.

A comprehensive approach that combines pressure relief strategies with individualised nutritional support can significantly improve patient outcomes and quality of life²⁹.

Lower functional independence is an indicator that nutritional supplements may be required, but all patients with pressure sores must receive a nutritional assessment, even if their malnutrition screening tool score doesn’t flag them for a dietetic referral³⁰. Slower healing and delayed wound closure can be exacerbated by protein deficiencies³¹.

Meta-analyses show that using oral nutritional supplements (ONS) to meet these deficiencies can significantly improve wound healing rates compared to those receiving a placebo³¹. When combined with standard wound care and nutritional education, ONS have also been shown to effectively improve the healing of wounds such as diabetic foot ulcers³².

They have even been shown to reduce the use of antibiotics in this patient group³³.   

Faster healing and reduced pain associated with pressure sores can significantly improve patient well-being and participation in rehabilitation, leading to overall better outcomes³⁴.

The use of wound-specific oral nutritional supplements is supported by a recent study which found that patients who were given specialised ONS had significantly lower wound areas and wound volumes at discharge than those who consumed their usual diet³⁴.

As a neurorehabilitation dietitian, where possible, I aim to prescribe ONS containing β-hydroxy-β-methylbutyrate (HMB), such as Ensure Plus Advance³⁵. HMB is a metabolite of leucine, an amino acid, that has been consistently shown to reduce the rate of muscle breakdown^{36, 37, 38}. HMB, arginine, and glutamine individually have properties that could support wound healing, such as promoting protein synthesis, collagen production, and immune function³⁹.

A pilot retrospective matched case-control clinical study found those receiving a combination of HMB, arginine and glutamine (HMB/Arg/Gln) had significantly faster rates of wound healing compared to standard care without HMB/Arg/Gln (a median of 170 days in the study group compared to 218 days in the control group)³⁹. However, there were no significant differences in relative healing rates between the HMB/Arg/Gln and standard care groups at any point during the 20-week study period.

The study suggests that the long-term addition of HMB/Arg/Gln to the standard treatment regimen for PUs in rehabilitation facilities significantly shortens the healing time of PUs in comparison to the standard of care regimen³⁹. However, the retrospective design and short study period, as well as lack of insight into the baseline health of the participants, makes this a study of low reliability. 

Small sample sizes and inconsistent methodologies remain a limiting factor in these studies, and confounders such as underlying medical conditions and baseline nutritional status could affect the reliability of the results. Factors such as cost remain a barrier to using such supplements in practice, as specialised ONS are often more expensive.

Dietitians should focus initially on patients meeting their protein requirements via food first approaches prior to using specialised supplements.