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Integrating Cognitive Strategies into thePhysical Therapy SettingDANESE MALKMUS

Effectively integrating cognitive management concepts into the physical therapysetting is dependent upon an adequate understanding of the cognitive andbehavioral consequences of head injury and the appropriate use of diagnosticand prognostic cognitive data as a basis for program design. The intent of thisarticle is to provide a framework for simultaneously addressing the physical andcognitive consequences of head injury. Behavioral manifestations of cognitivedysfunction and a means of clinically observing and assessing patient perform-ance are provided as a basis for program design. Specific examples of treatmentstrategies applicable to various phases of cognitive recovery are described.

Ke y W o r d s : Cogn ition, Cogn ition disorders, Head injuries, Physical therapy.

Rehabilitating the head-injured patient requiresreintegrating individual capacities within the limitations imposed by craniocerebral trauma and subsequent CNSdamage. Jennett and Teasdale indicatedthat the most consistent and debilitating consequenceof a head injury is some disorder of mental functioning, either temporary or perm anent.1 Bond's study onpsychosocial outcome of severe head injury indicatedthat family cohesion is affected more negatively bymental decline than byphysical disability.2 Griffith,3Ben-Yishay and D iller4 and others5- 7 confirm the highfrequency and significance of cognitive impairmentafter craniocerebral trauma.

The neurobehavioral consequences of head injuryconcern the professionals involved in rehabilitativemanagement. For those trained and skilled in physical rehabilitation, the cognitive, linguistic, emotion al,and social consequences of head injury are areas ofmajor consideration in designing and implementingtreatment programs. Most training programs providelittle preparation for effective management of theseareas. In working with head-injured individuals, theclinician soon realizes that traditional disciplinaryboundaries, roles, and approaches frequently are in-effective. A therapist cannot address the head-injuredindividual's physical deficits without also addressingthe cognitive and behavioral consequences of theinjury. The head-injured patient offers the cliniciana significant c hallenge, wh ich is the need to transcendtraditional, isolated rehabilitation approaches to ef-fect optimal management and outcome.

All professionals in the rehabilitative managementof head-injured patients are involved with the pa-tients' environment and with the behaviors demonstrated by the patients within that environment.Therefore, all professionals have the potential forfacilitating increased cognitive-behavioral function.The ability to influence the cogn itive recovery processpositively, while simultaneously addressing physicalmanagement objectives, is dependent on possessing aworking knowledge of the relationship of cognitionto behavior, the pattern of cognitive-behavioral re-covery after a head injury, and the strategies effectivein promoting such recovery. Given a basic understanding of these factors, the selection, timing, andsequencing of physical strategies and techniques be-com e clear, and the desired outcome is achieved morerapidly and easily.

This article provides the physical therapist with anenhanced understanding of the relationships of normal and pathological cognitive function to behavioralperformance and a means of observing and assessingpatient performance as a basis for determining andassessing clinical procedures. The primary thrust ofthe article is to illuminate the potential of the p hysicaltherapist for contributing to interdisciplinary cognitive management and to offer suggestions and examples for incorporating cognitive strategies into thephysical therapy setting.MANIFESTATIONS OF IMPAIREDCOGNITIVE FUNCTION

Behavior m ay beviewed as a product of mental orcognitive events. These events result from the interaction of cognitive processes that comprise a set of

Ms. Malkmus is a speech-language pathologist and Co-director ofThe Head Injury Center at Lewis Bay, 89 Lewis Bay Rd, Hyannis,MA 02601 (USA).

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internal structuring mechanisms. This internal ormental structure provides the m echanism for processing both internal and external information. Internalinformation entails such "things" as thoughts andemotions; external information comes from the environment through one's sensory channels. Cognitiveprocesses such as arousal and attentional mechanisms,analysis and discrimination, organization, association, categorization, integration or information synthesis, and mechanisms involved in the encodingstorage and retrieval phases of memory contribute tothe formation of internal or mental structure andinformation processing. Other mechanisms contributing to cognitive function are those involved in theinitiation, direction, suppression, and redirection ofmental activity. Adequate cognitive function involvesselective, goal-directed processing activity. It underlies, supports, and generates covert and overt behaviors. The integrity of an individual's behavioral responses is directly related to the integrity of thecognitive processes that serve as their foundation andgenerator and to the integration of these cognitiveprocesses, that is, how they function together as awhole.

Typically, stimuli from the internal and externalenvironments are fluctuating and random. Structureand stability are imposed by the selective focusing ofcognitive processes on relevant environmental elements. Diffuse craniocerebral trauma disrupts theneural structures that subserve cognitive-behavioralfunctions. This disruption results in a concomitantdisruption of the internal cognitive structure necessary for bringing organization and stability to theindividual's internal and external environments.8Such a breakdown in internal structuring mechanisms, or cognitive fu nction, results in the individua l'sinability to effect and maintain an appropriate balance or relationship between self and environment.The aberrant behaviors initially manifested by thehead-injured patient are directly related to impairedcognitive function and the individual's attempts tofunction in an environment beyond his processingcapacity.

The neurobehavioral changes in the head-injuredpopulation have a direct relationship to the structuralchanges in brain tissue that are a consequence of theimpact of primary forces on the cranium and thesecondary, pathological processes that further disruptand displace tissue. Although each injury and eachhead-injured individual are unique, the neurobehavioral changes subsequent to diffuse craniocerebraltrauma have many comm on characteristics. Once thebrain is no longer able to initiate, direct, suppress,and redirect mental activity adequately, the behavioral display of impaired cognition may include confusion; disorientation; impairment of attention, m emory, and learning; disorganization o f verbal and no n-verbal activity; and incompleteness of thought and

action. Responses may b e stimulus-bound, so that theindividual is unable to disengage from an isolated,irrelevant stimulus. At other times, he may be stimulus-dependent and encounter difficulty planning,implementing, and expanding thought and relatedactivity independent of an external stimulus. Difficulty monitoring, inhibiting, and shifting mental setsand, thus, behaviors, further reflects cognitive impairment. The individual can no longer structure andmodify mental processes nor deal differentially withthe multitude of stimuli normally available. He canno longer mentally structure external stimuli, fluidlyshift cognitive sets as his environment changes norstructure and modify his emotional reactions to thosechanges.8 Thus, the behavioral chaos demonstratedafter craniocerebral trauma is the result of cognitivechaos. The behavioral chaos reflects the head-injuredindividual's neurologically inadequate attempts toabate the cognitive chaos. If allowed to continue,these nonproductive, aberrant behaviors may continue indefinitely, impeding all areas of rehabilitativemanagement. Ultimately, these behaviors become ingrained patterns of inappropriate behavior.

COGNITIVE REHABILITATIONIn its broadest sense, cognitive rehabilitation is atwo-fold process of intervention. It involves implementing direct treatment strategies that address thespecific causal factors responsible for the breakdownin behavioral performance and indirect, complem en

tary strategies directed toward the individual's performance and the environment in which performanceoccurs. In other words, direct cognitive interventionis directed toward the head-injured individual's internal environment or those disrupted cognitive mechanisms that impose a negative effect on behavioralfunction. Indirect strategies address reorganizationand reinforcement of behavioral function and aredirected toward modifying the external environment.The success of cognitive intervention depends onusing both approaches: systematic reorganization ofcognitive function and environmental alteration thatreduces compounding sources of cognitive disruptionand increases patient performance. The enormity ofthis task only serves to point out the need for theparticipation of all professionals involved in managing head-injured patients.

Assessing Behavioral ResponsesRecovery of cognitive function follows a pathway

that is predictable and that may be described inbehavioral terms. As spontaneous neurologic recovery ensues and cognitive capacity increases, the head-injured individual's capacity to generate a greaternumber, variety, frequency, duration, and quality of

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TABLELevels of Cognitive Functioning, Recovery Phase andIntervention Approach

LevelII, IIIIVV, VIVII, VIII

Recovery Phasedecreased responseagitated responseconfused responseautomatic response

Approachstimulationstructurestructurecommunity

behavioral responses increases. These verbal and no n-verbal responses may be assessed using standardizedtesting methods or by observation and scaling systems. Observation and scaling of behavioral responsesis especially important during the early recoveryphase when the individual lacks sufficient cognitivecapacity to cooperate with testing.

One means of scaling and categorizing behaviors isavailable by using Levels of Cognitive Functioning,a behavioral scale representing the progression ofcognitive recovery as demonstrated through behavioral change (Appendix).9

This scale provides descriptions of behaviors frequently observed as positive neurologic change, andincreased cognitive integrity occurs over time. Indescribing the dynamics of cognitive recovery, thescale offers a common vocabulary and a baseline forestablishing and assessing treatment goals and techniques relative to cognitive capacity. Analyzing thebehaviors of a head-injured individual providesguidelines for the timing of physical strategies and forstrategies to improve cognitive function. Identifyingbehavioral cap acity offers a framework for appropriate expectations and interactions with the cognitivelyimpaired individual.

Level of cognitive functioning is determined byobserving patient responses within normally randomand fluctuating environments and in more structuredenvironments where stimuli are purposefully manipulated by the therapist. The therapist may alter theamount, complexity, rate, and duration of environmental stimuli presented at any given time whileobserving the effect on patient performance. Thedegree of consistency and predictability of the environment should be considered in relationship to behaviors demonstrated by the patient. The type ofbehavior demonstrated, the type of stimulus precipitating the behavior and the frequency, consistency,and duration of the behavior should be noted. 10 Applying these observation components will be discussed in relationship to cognitive levels later in thisarticle.

These obervations are important not only for determining an individual's level of cognitive functioning or predominant behavioral characteristics, but todelineate how patient performance may be affectedpositively or negatively in the treatment setting. Al

though the neurologic basis of cognitive disruptioncannot be altered, performance can be enhancedwhen the environment is altered to compensate forcognitive impairment.To simplify approaches for managing head-injuredpatients, the Levels of Cognitive Functioning may begrouped into four basic recovery phases and theirrespective management approaches (Table).11

Strategies for Decreased Response LevelsFrequently, the p hysical therapist is the only allied

health professional consulted during the earliestphase of recovery from a head injury. Thus, thephysical therapist is in an ideal position to addressnot only physical management concerns, but the individual's depressed state of responsiveness. A sensory stimulation program may be constructed andtaught to nursing personnel, family members, andothers having patient contact during the acute phase.Stimulation that may increase intracranial pressure,however, should be avoided. Physician consultationand approval should be obtained before implementing a program.This approach provides an organized presentationof heighten ed sensory input to prevent further sensorydeprivation, to encourage responsiveness to externalinput, and to monitor and to assess cognitive status.The approach assumes that the individual has thecapacity to generate responses to certain types ofsensory input when appropriately presented but acknowledges that injury may have impaired one ormore sensory channels. Therefore, the therapistshould assess responses to many types of stimulipresented to each sensory channel. Assessment isrepeated at various times of the day over a period oftime sufficient to determine times of maximum alertness and types of stimulation likely to elicit responses.Once this is determined, sessions are scheduled accordingly to gain optimal response.11

Because the individual's ability to maintain anoptimal state of responsiveness is limited, stimulationshould be provided at least several times daily but inrelatively brief sessions of 15 to 30 minutes. Thelength of time varies according to the time needed toeffect arousal and the individual's capacity to maintain a responsive state. Stimuli should be meaningfulto individual interests and preferences when possible.For example, a familiar voice or object is likely tohave stronger stimulus value than unfamiliar auditoryor visual stimuli. Th e therapist should present stimuliin an orderly manner to one input channel at a timeto avoid sensory overload and to determine whichstimulation produces the greatest response from theindividual. A brief explanation of the stimuli shouldbe given to the patient before, during, and afterstimulus presentation. Explanation and stimulus pre-

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sentation should not be simultaneous. Although theindividual may demonstrate limited capacity to respond to certain types of input, ongoing assessmentof responses to various types of stimulation is crucialto monitoring progress and upgrading the program.It is equally important to avoid overstimulating individuals with severely limited response capacity.Ideally, a balance of stimulation and rest is achievedthroughout the day that results in optimal responsiveness during stimulation sessions.11The individual is more likely to be responsive whenpositioned in a reclining wheelchair or on a tilt tablein the treatment area. The act of moving the patientto the equipment and positioning and interacting withhim verbally provides cutaneous, kinesthetic, andauditory stimulation that may contribute to increasedarousal and responsiveness. Upright positioning alsoprovides a more normal visual plane and change ofvisual environment. Wh en the patient is restricted to

his bed, visual, auditory, olfactory, cutaneous, gustatory, and kinesthetic stimulation may be brought tothe individual. The therapist may find it useful toorganize a sensory stim ulation kit containing a varietyof stimuli to carry to the bedside. Objects of variouscolors for visual stimulation, different textures forcutaneous stimulation, various sounds for auditorystimulation, and an assortment of scents for olfactorystimulation are useful items. Stimuli should be organized into categories, such as visual or cutaneous, andonly one type of stimulus used at a time. When atbedside, the therapist may introduce large, brightly-colored objects and encourage the patient to focus onthe stationary stimulus. If that is accomplished, thetherapist may move the visual stimulus gradually,encouraging vertical and horizontal tracking. Positioning programs, range-of-motion exercises, and oraland body hygiene provide cutaneous and kinestheticinput. These daily care routines may be integratedinto the stimulation program and the patient's responses monitored and assessed. I recommend maintaining a 24-hour record of stimulus input and response that is completed by all persons in contactwith the individual. Th ese strategies also may be u sedin the treatment area.11

W ithin the treatment setting, extraneous noise andvisual stimuli should be eliminated or minimized.Activities such as placing the patient on a bolster,large ball, or rocking board may elicit protectiveresponses or delayed but present balance reactionswhile providing vestibular, proprioceptive, and tactilestimulation. Intraoral and extraoral tactile stimulation may diminish tactile defensiveness and reflexdominated responses while increasing arousal andresponsiveness.11As responsiveness increases, efforts should be directed toward increasing the frequency, consistency,variety, rate of response, response duration, and the

ability to focus and sustain attention on a specificstimulus or activity. In this way, a foundation forpatient participation in the treatment proc ess is established. Once minimal attention and participation areachieved, responses may b e channeled into an activityused to facilitate increased focused attention andinformation processing. Simple activities requiringthe patient to attend to, discriminate, and emit amotor response will facilitate reaching this goal.11Catching and throwing a ball, hitting a tether ball,completing a step in a self-care sequence, or one -stepactivities such as selecting one of two colors, shapes,or sizes are examples of these activities.Strategies for Agitated Response Level

Agitation may be described as a transition fromminimal responsiveness to severe confusion. The behaviors demonstrated by the agitated patient represent confusion in its most severe form. During thisphase of recovery, the individual responds primarilyto his state of internal confusion and disorganization.He is essentially unable to attend to, to discriminate,and to process environmental stimuli or to monitorand to inhibit his responses. He is alert and hasprogressed from a state of hypoarousal to one ofhyperarousal but is incapable of cognitively generating planned behavioral action. Frequently, his disin-hibited, bizarre, and, possibly, combative behaviorsare viewed as psychotic, regressive, or uncooperative.This phase of recovery, however, represents progressand evolving cognitive recovery.10"12 Furthermore, thebehaviors are representative of a very frightened individual who lacks the neurologic and cognitive capacities to understand his situation. Measures such asisolation and medication usually have little if anydesirable effect; they tend to increase rather thandecrease agitation. Psychotropic medication used todepress agitation frequently must be given in massivedoses to be successful. Massive doses serve to depresscognitive function further and may cause undesirableside effects.11-13

The goal for this recovery phase is singular andbehavioral: progress the individual to the next levelof cognitive functioning. Effort is directed towarddecreasing the intensity, frequency, and duration ofagitated responses and increasing attention to theexternal environment. Such effort cannot be the soleresponsibility of the nursing staff. Allied healthprofessionals also can provide the time and resourcesto manage this recovery phase effectively. As agitation becomes apparent, assessment consists of determining which environmental stimuli precipitate,elicit, and increase agitated behaviors. Sources ofagitation should be eliminated when possible or, atleast, minimized. Assessment also includes determining stimuli that calm the individual. Stimuli or activ-

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ities that decrease the intensity, frequency, and duration of agitated behavior are the mechanisms forincreasing attention to the environment and movingthe individual through this recovery phase.11 ,12In most cases, human contact diminishes agitation,if only for brief periods of time. Noisy, heavily populated areas tend to increase confusion and, thus,agitation. Devices such as catheters, restraints, andnasogastric tubes are unfamiliar and uncomfortable.They compound agitation and should be avoided ifpossible. A so othing ton e of voice; verbal reassurance;orientation to time, place, and situation; gentle butfirm touching; or a drink or finger food frequentlyhave positive effects on behavior. Placing the individual in a quiet, highly structured group setting, withoutdemanding participation, often proves beneficial.Providing direction to the activity but allowing freedom of movement in a wheelchair or during ambulation in a quiet area absorbs physical energy anddiminishes hyperactivity. Frequently, the individualcan be engaged briefly in simple, automatic grossmotor an d self-care activities. If the therapist initiatesthe activity by handing an object or article to thepatient, the individual may automatically participate.Activities must be changed frequently because of thepatient's severely limited attention span. By frequently changing the activity, the therapist is able tokeep the patient engaged in brief but appropriateinteractions, which prolong attention span and reduceagitation.11,12

The approaches previously suggested are intendedfor the individual emerging from a decreased level ofresponse to a heightened state of confusion. Foreffective management, this phase of confusion hasbeen separated from the others. The strategies described are not intended for the individual who hasa habituated set of agitated behaviors, that is, theindividual with a behavior disorder. When managedeffectively, the individuals described in this articleusually progress through this phase in two to fourweeks. Although each o f the approaches described isnot successful with every individual, the therapistusually can determine and implement effective strategies. Such management certainly serves as a viablealternative to isolation, restraints, medication, orplacement on a psychiatric unit.

Strategies for Confused Response LevelsA structured approach also is used for confused

individuals who have progressed through the agitatedphase of recovery. These individuals continue to present severe cognitive impairment. Depending on theseverity of confusion experienced, they may behaveinappropriately or appropriately. Some degree of agitation may persist, but it is in direct response to w hat

is occurring in the environment. The approach forpatients functioning at a confused and inappropriateor confused but appropriate level of cognitive functioning is to provide sufficient environmental structure to compensate for persistent cognitive impairment and to facilitate optimum performance.

In the physical therapy setting, the activity and theinteraction between patient and therapist should beassessed relative to the amoun t, comp lexity, rate, andduration of information provided at any time. Forexam ple, the numb er of steps in an activity, the degreeof cognitive difficulty, the rate at which the activityis presented and carried out, and the duration ofactivity may exceed the patient's cognitive capacity.If the patient cannot comply with the requirementsof the activity, the therapist may alter any or all ofthe components to determine the effect on behavioralperformance. For example, the complexity or difficulty of an activity may be reduced for some individuals if verbal directions are eliminated or minimizedand visual demonstration and cues are substituted.The number of steps in an activity may exceed thepatient's attention span and short-term memory capacities. Participation may be enhanced by breakingdown an activity sequence into its component partsand proceeding one step at a time. Initially, theindividual may complete only one or two steps in thesequence. Performance also may depend on verbal orphysical assistance from the therapist. The rate atwhich instruction is provided and the rate at whichthe patient carries out the activity should be assessed.Frequently, when rate is reduced, performance escalates. Providing clear, concise instructions at a reduced rate of speech allows the confused patient moretime to process the information. Monitoring and reducing the rate at which the patient performs anactivity or the steps in an activity allows him sufficienttime to remember, o rganize, and carry out the appropriate behaviors. The d uration of an activity sequencealso is important to successful performance. Activitiesthat exceed a patient's attention span or tolerance forfrustration should be reduced in duration or eliminated until cognitive capacity increases. The physicaltherapist also should assess the treatment environment and how it affects patient performance. Thedecor and arrangement of the room, the number ofpatients and therapists, and the activity level mayserve to compound confusion and reduce appropriateperformance. The consistency of the approach, instructions, and treatment environment should be assessed. Ideally, the confused patient's schedu le, treatment setting, activities, instructions, and treatmentpersonnel are consistent from day to day. 11

In determining and assessing a treatment programfor the confused patient, successful and appropriateresponses are of greater conseque nce than the activityitself. In contributing to the cognitive rehabilitation

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of this patient, the therapist is working toward effecting consistently appropriate responses and facilitatingrecovery of the impaired cognitive processes. Theactivity is less important than the effect it has on theindividual's attention, retention, organization, andsequencing skills. The confused patient may cogni-tively benefit from simple, repetitive exercises. Breaking down repetitions into short sets and asking theindividual to count them aloud causes him to focusand maintain his attention on the activity. This goalmay be accomplished in individual sessions or, forexample, in a m at class designed to achieve cognitivegoals of increased attention to and retention andfollowing of directions. Maintaining a consistent routine from day to day and encouraging recall of theactivity and its steps promote memory function. Frequent orientation to time, place, therapist's name, andactivity performed provides predictability, enhancesmemory, and reduces confusion. As cognitive function improves, the cognitive and physical demandsand variety of activities may be increased gradually.11Functional training is best achieved in a settingwith minimal distractions, using a structured approach (see Rinehart in this issue). As the activity ismastered, more normal environments or distractionsmay be incorporated. Carry-over of performance intoother settings cannot be assumed, as learning is situation-dependent for each head-injured patient. Training must be provided in each setting in which theactivity is to be accomplished to assure safe performance. Attempts to teach unnecessary functional skills,such as wheelchair transfers to an individual who willbecome ambulatory, should be avoided. Such a taskmakes unnecessary demands on diminished memoryand is an inefficient use of time. Equipment need s forfunctional goals should be assessed early, and repetitious training should be implemented to take intoaccount any persistence of mem ory dysfunction. Caution should be taken in defining ambulatory status.Although the confused patient may be capable ofindependent ambulation on a physical basis, he mayneed supervision because of reduced cognitive function. Frequently, an indication of independent ambulation in the inpatient chart results in prematuredischarge. Describing the ambulation of the confusedpatient as independent to the family often leads toinappropriate expectations and may place the safetyof the patient at risk.

Strategies for Automatic Response LevelsWithin the familiar, predictable rehabilitation set

ting, individuals in this phase of recovery appeargoal-directed and frequently able to perform activitiesof daily living with physical independence. Duringthe previous recovery phase, a structured program

adapted the environment to the individual's co gnitivestatus and needs. Structure allowed him to functionin spite of reduced cognition and facilitated cognitiverecovery. Over time, he adapted to the structuredenvironment while function gradually improved. Although cognitive function also is improved at thisphase of recovery, if environmental structure andpredictability are altered, performance will be alteredas well. The individual's inability to integrate hisincreased cognitive, physical, and emotional capacities into the real world will become apparent.11

A community-based approach provides the head-injured individual an opportunity for reality testingand assistance in adapting his capacities to morecomplex environments. Concurrently, the programprovides the therapist with crucial information aboutthe actual functional status of the patient and whattype of intervention may improve it. This approachgradually reduces structure while increasing the individual's self-responsibility. Activities are selected topromote and integrate cognitive growth and physicaladaptation for the increased demands the com munityholds. These dem ands can be divided into three areas:activities related to self, home, and community. Ineach area, performance de man ds increase as structureis gradually reduced. Rehearsal, repeated trainingand practice, and patient-therapist feedback andproblem solving are an integral part of the process.11

Within the rehabilitation setting, self-responsibilities may include awakening on time, selecting appropriate clothing, initiating hygiene, dressing andgrooming, and arriving at appointments on time. Thephysical therapist may arrange to provide treatmentto other individuals on the patient's unit during thistime to observe and assess cognitive and physicalperformance during these activities. Other activitiesmay include appropriate use of unscheduled time,understanding the function of adaptive equipment,and setting up and performing routine activities orexercises. The physical therapist is important to thetraining, monitoring, and assessing of these activities.11

Home activities such as stripping and making thebed, organizing and maintaining personal supplies,doing laundry, and preparing a meal provide furtheropportunity for assessment and training. Performingcommunity activities, such as using public transportation, crossing the street, or marketing, are opportunities for assessing functional status. For example, theambulatory individual who crosses the street unsafelycannot be considered an independent communityambulator. As in earlier recovery phases, functionalstatus must be assessed relative to cognitive capacityand the individual's judgment and safety.11 Duringthis phase of recovery, the patient's improved cognitive function also allows the physical therapist abundant opportunity to refine motor-control functions.

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SUMMARYThis article has attempted to clarify the neurobe-havioral consequences of head injury and the expanding role of the physical therapist in integratingcognitive strategies into patient management. Centralto this issue is establishing short-term go als appropriate to the head-injured individual's cognitive capac

ity. Each set of goals should be viewed as steps in asequence leading to desired behavioral objectives thatare consistent with cognitive prognosis. As a memberof the interdisciplinary team who works consistentlywith the head-injured patient, or in some cases, theonly professional providing treatment services, thephysical therapist is in an ideal position to use strat

egies that will promote cognitive and physical recovery. When the therapist works in an interdisciplinarysetting, appropriate cognitive goals and guidance areavailable from those trained to assess and alleviatecognitive dysfunction. Professionals such as clinicalneuropsychologists, speech-language pathologists,and learning disability specialists welcome the opportunity to provide direction. Professionals in all disciplines involved in managing head-injured patientscan make appreciable contributions to cognitive management. This article provided a framework andguidelines to encourage the physical therapist's participation and to discourage the concept of brain-body dichotomies that further fragment the head-injured patient and impede optimal outcomes.

APPENDIXLevels of Cognitive Functioninga

Level Behaviors Typically Demo nstratedI. No Response: Patient appears to be in a deep sleep and is completely unresponsive to anystimuli.II. Generalized Response: Patient reacts inconsistently and nonpurposefully to stimuli in a non-specific manner. Responses are limited and often the same regardless of stimulus presented.Responses may be physiological changes, gross body movements, and/or vocalization.III. Localized Response: Patient reacts specifically but inconsistently to stimuli. Responses aredirectly related to the type of a stimulus presented. May follow simple commands in aninconsistent, delayed manner, such as closing eyes or squeezing hand.IV. Confused-Agitated: Patient is in heightened state of activity. Behavior is bizarre and nonpur-poseful relative to immediate environment. Does not discriminate among persons or objects; isunable to cooperate directly with treatment efforts. Verbalizations frequently are incoherent

and/or inappropriate to the environment; confabulation may be present. Gross attention toenvironment is very brief; selective attention is often nonexistent. Patient lacks short-term andlong-term recall.V. Confused, Inappropriate: Patient is able to respond to simple commands fairly consistently.However, with increased complexity of comm ands or lack of any external structure, res po nse sare non-purposeful, random, or fragmented. Dem onstrates gros s attention to the environment,but is highly distractible and lacks ability to focus attention to a specific task. With structure,may be able to converse on a social-automatic level for short periods of time. Verbalization isoften inappropriate and confabulatory. Memory is severely impaired, often shows inappropriateuse of objects; may perform previously learned tasks with structure but is unable to learn newinformation.VI. Confused-Appropriate: Patient shows goal-directed behavior, but is dependent on externalinput for direction. Follows simple directions consistently and shows carry-over for relearnedtasks with little or no carry-over for new tasks. Responses may be incorrect due to memoryproblems but appropriate to the situation; past memories show more depth and detail thanrecent memory.VII. Automatic-Appropriate: Patient appears appropriate and oriented within hospital and homesettings; goes through daily routine automatically, but frequently robot-like with minimal-to-ab sent confusion, but has shallow recall of activities. Show s carry-over for new learning, but ata decreased rate. With structure is able to initiate social or recreational activities; judgmentremains impaired.VIII. Purposeful and Appropriate: Patient is able to recall and integrate past and recent events andis aware of and responsive to environment. Shows carry-over for new learning and needs nosupervision once activities are learned. May continue to show a decreased ability relative topremorbid abilities, abstract reasoning, tolerance for stress, and judgment in emergencies orunusual circumstances.

a Abbreviated version from Hagen, Malkmus and Durham.8, 9

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REFERENCES1. Jennett B, Teasdale G: Management of Head Injuries. Philadelphia, PA, FA Davis Co, 19812 . Bond MR: Assessment of the psychosocial outcome of severe head injury. Acta Neurochir (Wien) 3 4: 5 7- 7 0, 19 763 . Griffith ER: Types of disability. In Rosenthal M, Griffith ER,Bond MR, et al (eds): Rehabilitation of the Head InjuredAdult. Philadelphia, PA, FA Davis Co, 1983, p 274 . Ben-Yishay Y, Diller L: Cognitive Deficits. In Rosenthal M,Griffith ER, Bond MR, et al (eds): Rehabilitation of the Head

Injured Adult. Philadelphia, PA, FA Davis Co, 1983, p 1715. Adamovich BL, Henderson JA: Treatment of communicationdisor der s resulting from traumatic hea d injury. In PerkinsWH(ed): Language Handicaps in Adults. New York, NY, Thieme-Stratton Inc. 1983, p 1056. Heiden J S, Small R, Canton W, et al: Se ve re he ad injury andoutcome: A prospective study. In Popp AJ, Bourke RS,Nelson LR, et al (eds): Neural Trauma. New York, NY, RavenPress , 1 9 7 9 , p p 1 8 1 - 1 9 37. Levin HS, Benton AL, Gro ssma n RG: Neurobeha vioral Consequences of Closed Head Injury. New York, NY, OxfordUniversity Press Inc. 19828. Hagen C: Language-cogn itive disorganization followingclo sed head injury: A conceptua lization. In Trexler LE (ed):Cognitive Rehabilitation: Conceptualization and Intervention.New York, NY, Plenum Publishing Corp, 1982, pp 131-149

9. Hage n C, Malkmus D, Durham P: Leve ls of cog nitive fu nctioning. In Rehabilitation of th e Head Injured Adult: Compre hensive Physical Management. Downey, CA, ProfessionalStaff Association of Rancho Los Amigos Hospital, Inc, 1979,pp 8 7 - 8 810 . Malkmus D: Factors influencing manag ement and outcom e:Cognitive considerations. In Rehabilitation of the Head Injured Adult: Compr ehensive Physical M anagement. Downey,CA, Professional Staff Association of Rancho Los Amigos

Hospital, Inc, 1979, pp 21-2311 . Malkmus D, Booth BJ, Kodimer C: Rehabilitation of the HeadInjured Adult: Comprehensive Cognitive Mana gement. Downey, CA, Professional Staff Association of Rancho Los Amigos Hospital, Inc, 19801 2 . Booth BJ, Doyle M, Malkmus D: Meeting the challenge of theagitated patient. In Rehabilitation of the Head Injured Adult:Comprehensive Management. Downey, CA, ProfessionalStaff Association of Rancho Los Amigos Hospital, Inc, 1980,pp 4 3 - 4 613. Berrol S: Medical assessment. In Rosenthal M, Griffith ER,Bond MR, et al (eds): Rehabilitation of the Head InjuredAdult. Philadelphia, PA, FA Davis Co, 1983, p 232

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