The project is being implemented with the support of UNICEF Ukraine and with financial support from the Government of Norway.
Implemented by: Partner:
Laura Sasso
U.D.G.E.E. Santa Marinella
12/07/2023
21/09/2023
Red Area and Neurosurgery
21/09/2023
10/04/2024
Riabilitative SubIntensive Care Unit
09/08/2024
19/09/2024
Pediatric
Riabilitative SubIntensive Care Unit
04 and 05/02/2025 Day Hospital
Neuroriabilitation and Adapted Physical Activity
Brain and Spinal Cord MRI:
- Cranio-spinal trauma;
- Probable dissection of the right internal carotid artery;
- Aneurysm with subarachnoid and ventricular hemorrhage.
CT Scan of the Brain, Facial Mass, and Spine:
- Multiple fractures of the skull base and cranial vault;
- No vertebral fractures (no spinal cord compression);
- Displaced fracture of the mandibular condyle and right orbital floor;
Chest and Abdominal X-ray:
- Bilateral pleural effusion;
- Perihepatic ascitic effusion;
- Displaced proximal diaphyseal fracture of the right humerus;
- Non-displaced distal diaphyseal fracture of the right radius;
- Non-displaced fracture of the right ischial tuberosity.
Medical and Nursing Procedures:
- Ventriculoperitoneal shunt (VPS);
- Central venous catheter (CVC);
- Nasogastric tube (NGT);
- Orotracheal intubation (IOT) → Tracheostomy (24/07);
- Intramedullary metal fixation of the right humerus with brace (17/07).
NEUROLOGICAL EXAMINATION
- Stuporous state;
- No seizures;
- Anisocoria with left mydriasis;
- Spontaneous eye opening, no ocular motility;
NEUROMOTOR PHYSIOTHERAPY
CONSULTATION
- Global hypotonia (with later hypertonia onset, major on the left side);
Therapy:
Baclofen and positioning orthoses for the lower limbs.
- Altered consciousness with chaotic environmental participation;
- Reducible distal hypertonia in the lower limbs with tonic-clonic jerks;
- Bilateral plantar flexion;
- Hyperactive deep tendon reflexes in the lower limbs, bilateral clonus;
- Spontaneous disorganized movements of the left upper limb.
- Periods of alertness;
- Ocular motility;
- Spontaneous motor activity on the right side.
RESPIRATORY PHYSIOTHERAPY
CONSULTATION
Tracheostomized patient with spontaneous breathing but dense secretions.
Parental educational training: Management of upper airway secretions, aspiration, and drainage.
Therapy:
- Passive mobilization and sensory stimulation as tolerated.
Parental educational training: Positioning and pressure ulcer prevention.
Supporting parents to:
- The mother is deeply distressed (feelings of guilt), struggling to understand healthcare staff communication;
- The father is lucid and stable.
Therapy: Weekly supportive counseling for both parents.
- Express their emotions and find resources to cope with uncertainty regarding N.’s condition;
- Approach the child and convey emotional closeness.
- Address communication difficulties.
The father improves in handling N.'s needs (aspiration, mobilization);
The mother remains in shock (anxiety, hyper-alertness);
Both parents regain hope through their child’s small improvements; They support each other.
Supine in bed Left hemiparesis
Left side Neglect
Nasogastric tube and tracheostomy;
Marked hypovision, but some ocular movements present; No verbalization
State of consciousness
Family
Residual functions
Side effects management (medicaltherapeuticalnursing)
Assistive devices/Orthoses
Pre-existing abilities
Coma Recovery Scale – Revised (CRSR):
Supine in bed:
- Generalized hypotonia, with emerging left hypertonia;
- Initially preserved ROM (later restricted in left foot and hand due to severe progressive hypertonia).
Medical Research Council Scale (MRC) for muscle strength:
- Right upper limb: MRC 2 (active movement in the absence of gravity);
- Rest of the body: MRC 0 (no contraction).
• No control of head or trunk movements;
• No autonomous postural transitions;
• Rare voluntary movements under tactile and verbal stimulation (right side);
• Left-sided neglect.
Gross Motor Function Measure-88 (GMFM-88): Non assessable
Assessment performed at the patient's bedside
• reduced facial expressiveness , head, and gaze turned rightward;
• Right-sided, third cranial nerve deficit, ptosis, exotropia and mild nystagmus in leftward gaze;
• Refusal of monocular vision in the left eye;
• In binocular vision, tracks objects only in the right visual field;
• Marked field restriction in the left visual field.
• No evident areas of altered sensitivity
• No evident pain
• No scars to evaluate or burns
Visual Analog Scale (VAS) for pain = 0 (genitore)
• Severe left upper limb distal hypertonia, clenched fist, functionally excluded;
• Latent but possible activation of the right side;
• Reduced spontaneous motor initiative;
• Grasping only with passive object placement by an operator;
• Global grip with strength and adaptation deficits;
• Basic cause-effect interaction with simple activation schemes (shaking/agitating);
• Movement facilitation through compensatory strategies: supine position, shoulder/elbow fixed on a support surface, proximal movements;Absent eye-hand coordination.
Melbourne Assessment Scale – 2 (MA-2) Non assessable
• Spontaneous breathing;
• Frequent aspiration needed due to secretion management difficulties;
• No oro-buccal movements;
• Feeding via naso-gastric tube.
• Possible unsupported eye contact
• Rarely chosen through the gaze with target in the right hemifield
• Amimic
• No verbalization
• If guided and supported, orients the right upper limb in the direction of an interesting game
• AFO positioning splints (prescribed in NCH) for:
• Preventing bilateral equinus foot deformity
• Preventing excessive external rotation of the lower limbs through lateral supports
• Nasogastric tube
• Tracheostomy
• Presence of a ventriculoperitoneal shunt
• Presence of a subcutaneous cannula and central venous catheter on the left side
Perinatal history: Normal pregnancy, full-term eutocic delivery.
Feeding history: Breastfed, regular weaning process.
Developmental milestones: Age-appropriate achievement of motor and language milestones.
Social integration: Recently enrolled in preschool.
Parents describe N. as:
- Intelligent - Talkative - Curious - Lively - Active and dynamic
Dal 21/09/2023
al 10/04/2024
MEDIUM-TERM GOALS
LONG-TERM GOALS
SHORT-TERM
GOALS
1. Short- and medium-term goals are influenced by fluctuations in consciousness level.
2. Long-term goals depend on the evolution of consciousness and the patient’s functional ability profile.
Why the child’s room?
• Continuous connection to monitoring systems is preferable.
• The patient’s physiological adaptation to the new setting is prioritized, minimizing the risk of hospital-acquired infections.
• Awaiting delivery of an appropriate postural system for patient transfers.
Negative aspects
- Limited availability of therapeutic equipment.
- Poorly adjustable lighting conditions for visual stimulation.
- Chaotic environment (high number of people, excessive auditory and visual stimuli).
Muscle Length and Range of Motion (ROM) – Hypertonia Management
• Manual therapy and stretching exercises: Cervical region, left upper and lower limb.
• Proprioceptive taping application on the left upper limb (Compression taping on fingers and wrist, Neutral taping on forearm)
Pressure Ulcer Prevention
Effective Coughing and Infection Prevention
• Postural hygiene and repositioning strategies
• Airway clearance techniques: Suctioning via tracheostomy when needed, bronchial clearance maneuvers in supine and lateral positions.
Stimulating Consciousness Recovery
• Environmental interaction Exploration of body space and peripersonal space.
• Tactile stimulation: Shape, texture, consistency, temperature.
• Visual stimulation: human face, lighted targets in darkened environment .
• Proprioceptive stimulation: Assisted sitting on the bed (perception of weight-bearing through pelvis and lower limbs).
• Updates on N.’s current condition.
• Recommendations for optimizing the patient’s room environment. Empathic Communication with Family
• Guidance on caregiving techniques.
↑ ↑ Visual-motor coordination and goaldirected movement
↑ ↑ Postural-motor and praxis-manual abilities
• Neuroplasticity stimulation
↑ ↑ Cognitive abilities
↑ ↑ Social-relational and communication skills
• Restoration of age-appropriate functional skills
• Potential return to independent living and age-appropriate activities
Head and Trunk
Control
Horizontal Postural Transitions
Functional Use of Vision
• Maintaining assisted sitting position
• Weight-bearing perception
• Upper limb support for postural stability
Right Upper Limb
Functionality
• Facilitated rolling to both sides
Left-Sided Perception
• Left visual field exploration with lightened or high-contrast targets in tasks of fixation and tracking from the midline towards the left peripheral visual field, following variable trajectories.
• In supine or seated position using a postural system.
• Orientation and facilitated reaching.
• Global grip strength and precision (gesture simplification, physical guidance, use of adapted objects in terms of shape, weight, and position).
• Eye-hand coordination.
• Functional use of familiar objects/gestures in social play.
• Sensory stimulation: tactile, pressure-based, vibratory, thermal.
• Passive integration in bimanual activities with a supportive function.
The SETTING moves out of the room NEUROREHABILITATION GYM
Prolonged sitting posture maintenance
Postural Hygiene
Perceptual containment
Control of distal movements (upper limbs)
Visual exploration
Social Interaction
Chewing and swallowing
Head: Rotation and extension in supine position.
Vertical alignment in sitting position (left inclination, right rotation).
Trunk: Sustained resistance in supported sitting
Removal of the headrest from the postural system. Head control exercises in an upright position.
Lower trunk support level.
Introduction of various seating surfaces (mat, roll, bench).
Postural balance activities.
Postural transitions: Lateral rolling to the left side.
Activities in prone and side-sitting positions.
Upper limb weight-bearing for support.
Right Upper Limb: Improved distal control and grip strength.
Reaching with variable trajectories and distances.
Global grasp and adaptive hand shaping.
Object transport and controlled release.
Left Upper Limb: Proximal movement with elbow extension through irradiation.
Consciousness : Increased intentionality and spontaneous activities.
Communication: Emergence of verbal production.
Application of neurotape to facilitate hand opening.
Orientation, targeting, and reaching in the left peripersonal space.
Eye-hand coordination
Environmental enrichment.
Enhanced intensity, frequency, and complexity of stimuli.
Oral motricity: Oral movements and tongue protrusion
Support for intentional communication.
Contextual communication.
Imitation and production of words
Development of oral motor skills
Implementation of correct feeding postures.
Adjustment of sensory responses to oral and perioral food stimuli.
Weaning from nasogastric tube (NGT).
Weaning from tracheostomy (CET).
Caregiver education.
Swallowing training with semi-solid homogeneous foods + chewing with non-food aids
Increased food intake + liquid integration + dual consistence trials.
Progressive weaning from the nasogastric tube.
Trials of phonation valve occlusion
24-hour capping of the tracheostomy
POSITION
Head Control
Trunk control Stability
Static Balancing
Left-sided hypertonia
Facial muscle weakness on the left side
Weight-bearing on the lower limbs
Anticipatory responses
Support strategies
Non-use of the left upper limb
Upper limb functional use
Protective reactions
Balance responses
Muscle strength deficit (greater on the left side)
Left foot in plantar flexion
Pelvic and lower limb strengthening
• Postural transitions (quadrupedal and kneeling positions with facilitation).
• Sit-to-stand training (with AFO) supported by the therapist.
• Prolonged standing posture with KAFO.
• Short-term standing with AFO, anterior table support, and therapist-assisted lower limb stabilization. Verticalization
• Vestibular stimulation. Body perception enhancement
• Visual feedback on posture.
• Weight distribution perception on hemipelvis and plantar region.
• Visual feedback.
• Manual therapy. Facial re-education
• Myofunctional stimulation.
• Continuation of previous orientation, targeting, and reaching activities with hand opening in the left peripersonal space.
• Integration of the left upper limb in maintaining various postures.
- Increase in Support Reaction
- Trunk balancing exercises in static position
- Mobility/stability exercises for the pelvis
- Weight perception on lower limbs
- Knee and tibio-tarsal alignment and support
- Maintaining Prolonged Standing Position
- Reduction of knee support while preventing recurvatum
- Weight-shifting exercises between lower limbs
- Simultaneous and selective control exercises of different body segments
Environmental misperception
Fear of falling
Frustration and refusal
Verbal and motor stereotypies
Lack of parental coping strategies
Coma Recovery Scale – Revised (CRSR):
Full recovery of consciousness
Evolution of the clinical picture
• Increased muscle tone in the left hemibody (greater in the upper limb)
• Passive range of motion maintained Medical Research Council Scale (MRC) for muscle strength:
Right hemibody: 4 - Active movement against gravity and resistance
Left lower limb: 3 - Active movement against gravity
Left upper limb: 2 - Active movement with gravity eliminated
• Head and Trunk Control
• Increased endurance in physical activities
• Cooperation in postural transitions
• Standing position with orthoses
• Emergence of balance reactions
Gross Motor Function Measure-88 (GMFM-88): 15% (target areas A and B)
ASSESSMENT Conducted in a Normally Lit
Environment
• Anisocoria (left pupil larger than right)
• Photophobia
• Exotropia in the right eye
• Hypofunction of the right medial rectus + hyperfunction of the right lateral rectus
• Fixation with the left eye (>3 meters)
• Horizontal and vertical tracking, fragmented circular tracking
• Evocable saccades
• Insufficient convergence
• Good contrast sensitivity
• Visual acuity (Lea Symbols): Right eye: 3/10, Left eye: 9/10
• Right arm: Direct object approach, global grasp, and superior pincer grasp for small objects
• Left arm:
Proximal: Ability to lift the arm to shoulder height and extend the elbow Distal: Hand remains closed
• Improved eye-hand coordination on the right side
• Poor bimanual integration
• Praxis: Three-step sequences, evolving feedback and monitoring ability
Communication and Language
Phono-Lexical Test (TFL)
Lexical comprehension: 50th percentile
Lexical production: 50th-75th percentile
Children’s Socio-Conversational Skills Test (ASCB):
Assertiveness: Between infrequent and emerging
Responsiveness: Acquired competence
Emerging initiative and communicative intentionality, though not always functional
Simple sentences (Subject-Verb)Emerging ability to narrate single events
Gestural support useful for communication
• Spontaneous breathing
• Phonatory valve in place
• Nasogastric tube removed
• Manages solid foods and mixed consistencies
• Drinks liquids from a glass
• Eats independently ADLs
• Load-bearing showers (KAFO)
• Leg-foot orthoses (AFO)
• Postural system (Xpanda)
• Tracheostomy present
• Ventriculoperitoneal shunt present
