Intervention Goals and Treatment Strategies

Question 1

Nonresponse to Early Response Stage

Answer 1

RCLF Adult I-III Pediatric RCLF V-III- unable to follow commands
Primary purpose of PT in this stage is prevention of complications

Prevention of MSK complications:

• positioning- prevention of contractures and minimization of asymmetry, avoid supine (promotes dystonic posture or reflex hyperactivity), encourage side lying or prone positioning with pillows placed to avoid pressure on bony prominences
• PROM- slow progression with care to avoid stretching at end range, should describe to child what is being done
• splints or serial casting- effective for short term prevention/correction of contractures, serial casting primarily used after contractures develop, casts should be change regularly for continuous assessment
• Passive/assisted sitting and standing- vital signs stable, use of tilt table to load bones/stretches/stimulates internal functions (BB), promotes lung expansion (improved ventilation)–> monitor vitals, should stand 30 minutes 7x/week until child can complete unsupported standing

Sensory Stimulation- stimulate 5 senses directly and child responses are assessed with intent of advancing sensory complexity as child progresses

Family Edu- encourage participation, instruction on proper care giving, transfers, bed mobility, contracture preventions, and checking skin integrity

Question 2

Vegetative State and Minimal Conscious State

Answer 2

Absence of an adequate response to the outside world and absence of any evidence of reception or projection of information in the presence of a sleep wake cycle

May have periods of restlessness with open eyes and movement, but responsiveness is limited to primitive postural and reflex movements of the limbs

Limited self awareness, but do feel pain and have sleep-wake cycles

Result of primary brain damage, vegetative state is not an extension of a coma. A coma is a transient state

Spasticity and mm contractures- 2 common features of vegetative state

• maintain ROM
• may need pharmacologic intervention
• may see Botox used

Question 3

Agitation/confused Stage

Answer 3

Adult RLCF VI-V Pediatric RLCF level II- may follow simple commands with impaired judgment and problem solving ability–need constant supervision to prevent injury

Procedural interventions and patient-related instructional activities to achieve treatment goals:
- Directed activity, increasing child’s motivation for activity, family education

Directed activity and increased motivation can be achieved through:

• Simple task training- functional activities can be learned using procedural and implicit memory through repetition of tasks with appropriate orientation. Child exhibits frequent errors and variable performance at this stage. Important to provide practice and feedback. Children with TBI often fail to act without extensive cuing. Want highly structure, consistent and reinforcing of environment is important to ensure participation.
• Modification of task to ensure success- must be creative to keep child focused and increase motivation, activities need to be relevant to child’s needs, complex movements may result in increased frustration at this stage
• Building a Structured Environment- calm environment with structured stimuli enhance child’s ability to follow commands, identify environmental variables that effect child’s behavior both positive and negative. Want to eliminated negative factors and replace them with those that reinforce the desired behavior. Progress and modify to further facilitate improvement.
• Carrying out many short term interval treatments- child has short attention span and tolerance. Multiple short treatment sessions maximize the child’s alertness and attention to therapeutic tasks

Family Edu- consistent schedule of ADL’s and therapy, need close supervision, implement goals into daily routine, repetitive task practice leads to gradual improvement in motor performance as child re-acquires motor skills.
- Child can often become agitated and bored during this stage

Question 4

Higher Level Response Stae

Answer 4

RLCF pediatric I and adult VI-VIII- less confusion that previous stage, improvement in short term memory, more appropriate and focused behaviors, increased interaction with others and the environment. Limitations of insight, abstract reasoning and problem solving can still exit. Community re-integration, child is relatively independent at this stage. Focus on skills that will assist child in meeting self-care, social ,and educational goals.

Practice progressively challenging tasks- provide opportunities to actively participate in and practice meaningful and motivating activities. Common for children to show improvement in practiced tasks with difficulty generalizing tasks to other contexts. Ex. constraint induced therapy and body weight support treadmill training.
–Info about child’s learning capabilities can be determined by: number of reps needed to learn a new task, ability of child to do same task the following day, and ability to do same task in different contexts

Reduce environmental restrictions- PT may modify task or environment to adjust the difficulty of the functional activity. Ex. gait training inside on level surface then walking outdoors then walking on uneven surfaces

Increase physical conditioning- weakness is common impairment in children with ABI. Heart rate found to be significantly higher in children with ABI compared to healthy controls. Encourage aerobic activity through activities with peers or through developmental activities depending on child’s age