Evaluation & Treatment

Initiate OT intervention, as appropriate, given the patient’s medical status, precautions, and activity orders as indicated by the medical team. Refer to the contraindications/considerations for treatment section for more information.

Treatment planning should follow two basic principles: 1) clearance from the RN for the patient to participate and 2) make sure the RN understands what the physical demands of the treatment will be (Popovich, 2011). The patient may only tolerate short sessions (10 to 30 minutes) at first. Sessions can consist of AA/AROM, orthostatic stress challenges, and assisted ADL. Advancing activities from bed level to supported sitting to unsupported sitting and finally to standing (Popovich, 2011).

Focus Starting on Admission

• Medical optimization: ICP, BP, weaning of sedation, nutrition, sleep/wake

• ROM/positioning

• Environmental/sensory regulation

• Early consults for OT, PT, and SLP as appropriate

• Early mobility to decrease risk of confounders (see below)

• Use of standardized neuro assessments (GCS & CRS-R)

• Interdisciplinary rounds to coordinate care and identify potential barriers to discharge early

• Family counseling/education

Evaluation

Key components include:

• Multiple evaluations overtime with different modes of assessment (i.e., outcome measures/standardized assessment) by multiple examiners (i.e. shouldn't only be OT or PT evaluating but entire team to get the holistic picture)

• Assessment should be performed in an optimal environment at various times of day

• Look for confounders for the assessment of consciousness (see below)

Confounders

Things to be aware of for all patients in the Neuro ICU:

• Motor deficits (i.e., paralysis or spasticity)

• Cranial nerve and vision deficits (i.e., CN III palsy)

• Additional sensory deficits (i.e., hearing)

• Higher-order cognitive deficits (i.e., aphasia and apraxia)

• Sedating medications

• Hypoactive delirium

• Complications: Hydrocephalus, fever, pneumonia (PNA), subclinical seizures, urinary retention, urinary tract infection (UTI), and/or neurogenic bladder

Considerations when working with the patient

(Hamby, 2017; Padilla & Domina, 2016)

It is critical to implement a systematic approach for both assessment and treatment. Evaluation of a coma patient should be focused on identifying subtle signs in response to sensory stimulation. A typical evaluation of body functions should be performed along with careful observation of changes in vital signs in response to task performance. The overall goal is to facilitate the patient’s ability to interact with their environment.

General Tips:

• Give simple, 1-step commands that are 5 words or less allowing for plenty of time for the patient to process the information (30-60 seconds) before repeating the instructions.

• A quick “cognitive screen” can be completed to better assess yes/no response (i.e., ask the patient “is the sky green?”, “is the ocean blue?”, “Are there fish in the sea?”)

• Reduce demands, minimize distractions, and regulate amount of sensory input provided at one time to account for decreased frustration tolerance and decreased attention span.

• Provide structure, consistency, and orienting information

• Utilize gross motor activities or movement to mitigate agitation

• Refrain from constantly drawing attention to deficits, this can increase frustration

• Try to redirect unsafe behaviors, but do NOT engage in arguments with the patient. When possible, switch topics/tasks.