How should occupational therapy treat patients with craniocerebral injury?

When making occupational treatment plan, we should first understand and master the general state of patients through careful and thoughtful evaluation, and then make different treatment plans and choose corresponding treatment methods according to the stage of patients. Therapists should closely observe the changes of patients in all aspects at any time, communicate with other professionals in the group in time, and adjust the treatment scheme and means at any time.

For the occupational treatment of patients with craniocerebral injury, some can refer to the treatment of stroke. However, because patients with craniocerebral injury sometimes have not only one limb paralysis, but also bilateral limb dysfunction, coupled with the decline of understanding, memory and spatial recognition and emotional disorders caused by late brain dysfunction, the training process will encounter more difficulties and more complicated situations than stroke patients. Therefore, the therapist must have a high sense of responsibility, persistent patience and necessary professional knowledge, and make an evaluation during the treatment.

According to the clinical characteristics of craniocerebral injury, occupational therapy can be roughly divided into the following stages:

The first stage: lethargy or consciousness and reaction to external things, but difficult to deal with.

The second stage: it is difficult to accept your own changes, and your mood fluctuates greatly, which is not suitable for the real state.

The third stage: gradually accept and adapt to reality.

The first stage of treatment

1. The evaluation of patients in the first stage of functional evaluation is actually the evaluation of early intervention treatment. Because of the rapid change of the disorder characteristics of patients with craniocerebral trauma, early intervention is needed. When the patient is in a coma, the main evaluation contents of early intervention treatment are consciousness level and limb function. The main purpose of early intervention treatment is to maintain the limb function and cognitive ability of patients and prevent secondary disorders. If the patient's consciousness level is in a normal state, the specific evaluation content is as follows:

(1) Cognition: How did the patient react? Can you respond to simple verbal commands? Such as "shake my hand", can the patient communicate with words or eyes?

(2) Vision: Can patients see things or therapists with their eyes? Can you open your eyes when you hear the sound?

(3) Feeling: Can patients respond to external stimuli? As in response to pain or cold.

(4) Joint mobility: Is the patient's joint mobility limited? If so, it is necessary to judge whether it is due to increased muscle tension or spasm after denervation of cortex or brain, or joint contracture.

(5) Muscle strength: Is the patient's muscle group weak under continuous tension?

(6) Motor control: Does the patient have cortical or cerebral rigidity? Are there any spasms or hypotonic states with increased tension? Is one limb, one limb or both limbs involved? Is there an original reflection?

(7) Swallowing status: Does the patient eat by himself? Do you cough?? Can the patient keep his mouth shut and not leak food or drool?

(8) Social psychology and behavior: Is the patient quiet or emotionally unstable?

In the first stage, the evaluation of patients is generally completed by means of protractor unarmed muscle strength detection, traditional nervous system examination and clinical observation. GCS coma scale and RANCHOSLOSAMIGOS scale are often used to evaluate the cognitive level of patients in this period.

2. Occupational therapy Generally speaking, the goal of the first stage of occupational therapy for patients is to improve their reaction level and their understanding of themselves and the environment. If the patient's vital signs are relatively stable, the patient should be allowed to do all kinds of sitting training, eat in the sitting position as much as possible, prevent long-term bed rest, and prepare for the next occupational therapy in the occupational therapy room.

The main contents include: the application of orthosis to stimulate correct sitting posture by good posture perception, the treatment of dysphagia, the treatment of behavior and emotion, and the education of family accompanying.

(1) Maintain good posture and range of joint motion: When the patient is in a lethargic state at the initial stage of the disease, it is likely that it is difficult for the patient to maintain a good posture due to abnormal posture such as relaxation or spasm of the original reflex, or drug treatment of fracture and some artificial actions, such as clean and hygienic nervous system examination. On the one hand, bad posture may cause skin damage and ulcers, on the other hand, due to uneven muscle tension. It is easy to cause joint contracture deformation and abnormal posture. Based on the above reasons, it is effective to adopt good lying posture, change posture regularly and passively assist joint activities. (2) Perceptual stimulation: In the early stage of the onset of patients with craniocerebral injury, occupational therapy also has an important job, which is to improve and improve the patient's consciousness level through controllable perceptual stimulation. Perceptual stimulation can be implemented from the early stage of the patient's semi-lethargy or lethargy.

There are many ways of perceptual stimulation, and generally visual, auditory and tactile stimulation can be used.

1) field of vision: let the patient sit in bed or wheelchair. This action itself can make the patient get rid of the visual environment that only sees the ceiling. Gazing at the surrounding environment itself is the most basic visual function training. On this basis, further guide patients to pay attention to people and things in the surrounding environment.

2) Hearing: Use sounding objects such as bells and rattles to sound in all directions, and practice the patient's response to auditory stimuli. Generally speaking, the patient's response is to tilt his head in the direction of making sound. Sometimes visual stimulation and auditory stimulation can be performed at the same time.

3) Touch: Take superficial feeling as an example, rub rough or soft cloth on the patient's skin surface to guide the patient to point out the rubbing part. Before perceptual stimulation training, the therapist should understand the patient's life personality and hobbies before injury in order to give him more meaningful sensory stimulation. Under normal circumstances, patients are easy to respond to the language requirements and breath of their families, but it is more difficult for professionals. Therefore, from the initial stage of treatment, the treatment group should include a family member, which is very helpful to improve the treatment effect. With the progress of training, patients who respond to sensory stimuli and verbal commands should be trained with sensory stimuli with similar functions.

(3) Correct sitting posture: Sitting posture is very important, because whether sitting in bed or wheelchair, it provides patients with an opportunity to directly contact with the surrounding environment in an upward posture. Correct sitting posture can prevent pressure sores and joint contracture, promote muscle tension, inhibit primitive reflex and improve patients' cognitive function.

(4) Use of splint and orthosis: Early use of splint and orthosis is mainly used for: ① spasm restricts patients' functional activities and causes ADL dependence; ② Limited joint movement; (3) There is possibility of soft tissue contracture. Splints for hands and wrists are often used to maintain their functional positions and reduce muscle tension during rest (see Chapter 4 Treatment of Stroke in this book for details). The correct use of splint is to wear it alternately for 2 hours. Nurses and nursing staff should master the correct method of wearing splints and learn to regularly check whether the skin is damaged.

(5) Dysphagia: Coma patients can eat with stomach tube. Once the patient adapts and can cooperate, the doctor can decide when to remove the gastric tube. The evaluation of dysphagia and the beginning of their training often begin after the patient's condition is further improved.

(6) Behavioral and emotional treatment: When patients gradually get familiar with the surrounding environment, there will often be a chaotic emotional instability or indifference. For the initial patients, the therapist should be calm and patient, and introduce the duties of the therapist to the patients again. If the patient's mood is unstable, give him enough time to express his feelings and let him feel his needs. When the patient's chaotic situation is relieved and his cooperation ability is improved, he should choose a quiet environment to start treatment, at least.

(7) Guidance of family members and caregivers: It is a useful way for family members and caregivers to participate in the treatment group, which can effectively obtain the cooperation and help of family members in the rehabilitation process. They can provide information for treatment, help to maintain correct bed posture during sensory stimulation, and can participate in joint activity training. When the patient is awake and able to move, it can directly help the patient to maintain the correct posture, eat and ADL training in the wheelchair. In addition, because family members and caregivers may be afraid and emotionally out of control, therapists should give them psychological support while giving guidance. For therapists, it is very important to respect the needs of family members to express their feelings and let them feel that their concerns are understood by therapists.

(2) the second stage of treatment

In the second stage, the patient is awake, but often shows confusion, vacillation and inappropriate response. The evaluation of patients in this stage is similar to that in the first stage, including physical condition, swallowing, perception, cognitive function and so on. In addition, it is necessary to make a broader assessment of ADL's working ability and ability to return to society. Because the patient's attention can't last long, it may take many times to complete.

The treatment at this stage mainly includes two aspects: rehabilitation mode and compensation mode. The former is based on the theory of neuroplasticity, and the latter is usually accomplished through the transformation of appropriate equipment environment and the use of contralateral compensation.

1. The assessment of limb condition includes joint range of motion, perception, motor function and activity control ability.

Prerequisites for normal exercise include: normal posture tension, controllable overall balance of flexors and extensors close to normal and stable state, and the ability to implement selective exercise mode, which will weaken or disappear posture reflex due to spastic soft tissue contracture, thus affecting patients' independent activities and normal control ability.

The general principles of limb motor function rehabilitation training for patients with craniocerebral injury include: promoting the control of muscle groups from proximal to distal, promoting the symmetrical maintenance of posture, promoting the integration of limbs in activities, and obtaining correct sensory experience.

For its treatment, please refer to the treatment of stroke in the fourth quarter of Chapter 4 of this book. )

2. Assessing the swallowing status of patients should include clinical observation and imaging examination. Clinical examination can help examiners to determine whether the cause of dysphagia is emotional impulse (whether the patient wolfs down, leading to poor breathing and suffocation) or limited oral movement (whether the patient can exercise food or hold food with his mouth; Whether the patient can handle saliva or obvious drooling when eating; Clinical examination can also provide therapists with cognitive function (whether the patient knows the purpose of tableware and the kind of food), perceptual ability (whether there is unilateral neglect) and language function (whether the patient can name the tableware, whether there is aphasia or dysarthria).

Imaging examination is necessary. Through imaging examination, it can be determined whether there are structural or physiological diseases in the mouth, throat and esophagus that affect swallowing function, so as to judge whether the patient has the ability to handle solid and liquid food. This information can be used to design a diet plan.

It should be noted that improper posture, behavioral disorder, cognitive impairment and sensory impairment will all affect the swallowing function of patients.

In view of the above swallowing problems, therapists need to cooperate with clinicians and speech therapists and take necessary measures according to the situation. For example, in the case of insufficient sucking ability, you can gently stimulate your mouth and lips with things like pacifiers to induce sucking action; In addition, putting a small amount of food with sour taste in the mouth is helpful to induce the emergence of sucking reflex; Tongue movement in all directions plays an important role in food chewing and swallowing. Without proper tongue movement, food cannot be transferred to a position in the mouth that is conducive to chewing and swallowing. When the tongue muscles are not moving smoothly, sticky food such as sorbet or jam can be applied to the patient's mouth to guide the patient to lick this action with his tongue, which is very beneficial to promote the tongue movement function. When the swallowing function of the patient is weakened, the food can be made into mixed and moist small pieces for swallowing.

3. The treatment of perceptual disorders includes the treatment of some common agnosia and apraxia.

(1) Unilateral spatial agnosia: Occupational therapy for unilateral spatial agnosia can be divided into two stages: bedridden stage and bedridden stage.

1) Bed rest period: The basic starting point of treating unilateral spatial agnosia is how to let patients know the space of agnosia. The simplest way is for the therapist to greet and train the patient from the perspective of agnosticism, and at the same time allow the patient to read. It can also make the target object move to the agnostic side in the field of vision, so as to track the object whose line of sight moves to the agnostic side. Without turning his head, he can point his finger to the agnostic side of the patient along the line of sight. Sensory stimulation, such as tactile pulling, massage, cold, etc. You can also let the patient move or stimulate the paralyzed side by himself, or you can let the patient move his limbs across the midline to the opposite side to obtain urgently needed items deliberately placed on the agnostic side of the patient. Brightly colored objects or flashlights can be used to attract patients' attention to the affected side.

Occupational therapies suitable for bedside deployment include:

(1) All treatment-related personnel greet and talk to patients from the perspective of agnosticism as much as possible.

② When listening to the radio, put the radio on the agnostic side to give the patient auditory stimulation.

(3) patients can read books and newspapers, and topics can be started on the content.

④ Moderate exercise training.

⑤ When eating, rotate the plate 180 to attract patients' attention to the food on the unidentified side.

⑥ Instruct family members and caregivers to greet and talk with patients from agnosia.

2) Bedleaving period: If the patient can sit in a wheelchair or bedside for more than 30 minutes, he can enter the occupational therapy room with the permission of the doctor for more detailed and targeted occupational therapy.

The specific processing contents are as follows:

A. Ways to promote functional recovery and reorganization: specifically, training to explore objects on the desktop or screen through vision; Training to move the stick to the agnostic side; Cartography and jigsaw training; Training in selecting and placing cards; Training of sand pushing plate mill; Joint range of motion training; Training moves the throwing circle from the healthy side to the agnostic side; Throwing a sponge ball for training, deliberately throwing the ball to an unknown party during training; Transfer training, mainly practicing the movements from bed to wheelchair and wheelchair to bed; Manipulation training of trunk rotation movement, etc.

Patients with unilateral spatial agnosia, if they still use the commonly used contralateral transfer, often only the contralateral side works, and the diagnosed paralyzed side does nothing. For example, when a patient is transferred from a wheelchair to a bed, the muscle strength of the patient's contralateral side is sufficient, even if the affected foot does not play a role on the pedal of the affected side, the patient can complete the transfer only by playing the contralateral side. However, if the patient starts to do bypass from the affected side, it will be difficult to complete because of the problems in the affected side. Therefore, letting patients do transfer training from the affected side can make patients pay attention to the affected side and realize that the affected side can't complete the transfer without exercise. If the motor function of the affected limb is above Brunnstrum level, the patient can carry out transfer training on the affected side.

B. integration method: according to the degree of patients' unilateral spatial agnosia, various training methods are integrated into specific treatment stages to form staged treatment, so as to achieve the purpose of staged treatment. When treating, it is best to choose a single room or a quiet place, so that the healthy side of the patient can be against the wall, and the therapist can choose stimulation on the agnostic side for treatment. There are several specific methods:

A. Intersensory integration: This is a method to achieve integration by using various sensory stimuli. Visual step-by-step training:

From the narrow horizontal line to the plane topic, from the healthy space to the agnostic space; By controlling the size and number of objects in the exploration space, it is gradually realized; In the training of finding an object, gradually control the difficulty of finding an object; The treatment object tracked continuously in the exploration space will gradually develop into the treatment object tracked in the exploration space, and the eyeball will move discontinuously and greatly in all directions.

Training of hearing and body sensation: Similarly, intensive training is gradually carried out according to the degree to improve the understanding of the agnostic side.

You can turn over to the agnostic side, and when you lie on your back, your center of gravity moves to the left and right, so that the agnostic side can emphasize the feeling and improve the cognitive ability of the body. The load on the agnostic side when sitting in a chair and standing can promote muscle contraction and improve the understanding of the body.

B. Integration method between different senses: While strengthening the senses and expanding the perceptual space, different senses can also be integrated to improve the understanding of agnostic space.

Hearing and vision: When doing building block training to explore space, auditory stimulation can be applied step by step to promote the expansion of agnostic space, and speaking from agnostic side is helpful to promote the development of visual exploration to agnostic side.

Body feeling and vision: promote vision through visual exploration, and shift the weight to the agnostic side at the same time; In visual exploration and hand grasping training, head movement and upper limb operation are added to promote the visual and visual space cognition of agnostic side, and the visual cognition of agnostic side is induced through posture control.

Through the correct integration of vision and body sensation, the normal posture response can be promoted, and then through the appropriate strengthening of auditory stimulation, the sensation can be correctly fed back, which can effectively improve the unilateral spatial agnosia, effectively extend the results of various sensory integration to PADL and IADL, and improve the ability to complete daily life.

C compensation method: when the patient's function is difficult to fully recover, compensation method can be used.

A. Use clues to promote the attention of the agnostic side: in the training of visual exploration objects, add red clues to the agnostic side of reading training and eating tableware and aisles to promote the attention of the agnostic side.

B. Ways to promote the agnostic's attention: set up daily activities around the healthy side space that patients can know, such as putting the light switch and TV pager on the healthy side, sticking tape on the ground to indicate the way back to the ward, marking the door, etc. This compensation method can be used when the patient's function has not fully recovered.

D vestibular stimulation: all kinds of vestibular stimulation methods can improve the symptoms of patients. For example, the proprioception stimulation of the left transcutaneous nerve can stimulate the neck muscle-the vibration of the left posterior neck muscle and the rotation of the neck in different directions can stimulate the vestibule, which is helpful to improve the visual intention technology in symptom memory disorder. It is also effective for this symptom.

E. Activities of daily life: Practice the items of daily life activities repeatedly, break down the patients' daily life activities in detail, and let the patients tell the key steps themselves, so as to practice the completion of daily life activities, let the patients watch the images of patients' daily life activities taken by the camera, clearly and timely feed back the mistakes of patients' own actions, and make targeted corrections.

The patients with visuospatial agnosia can recover to the level of self-care of daily activities when the dyskinesia is mild, but can only recover to part of the level of self-care of daily activities when the dyskinesia is severe.

F. Environmental aspects: including three aspects.

A. Supplies and equipment: When dressing, you can choose clothes with obvious signs on the front, back, left and right, or sew obvious signs; If the patient often forgets to pull the wheelchair handbrake, a mark can be made on the pedal or where the wheelchair should be parked, so that the patient can park the wheelchair in the correct position.

B. Living environment and equipment: For patients with hemianopsia who want to stay in the ward, the position of the bed should be adjusted as appropriate according to the influence of hemianopsia on the patient, such as the relationship between the light switch and the position of the bed and the position of the TV.

C. Surrounding humanistic environment: Close communication with the family members of therapists, nurses and other professional nurses is conducive to evaluating and deepening understanding, determining the patient's state according to the evaluation results, and deciding the treatment policy and implementation method together with relevant personnel.

G. Family members and patients: Family members should be given guidance and help. Family members can often accompany patients and stimulate them at any time, which is of great auxiliary significance in treatment. To guide and help family members, first, we should understand the patients and master the best treatment methods. Therapists should also pay attention to giving spiritual support and guidance to patients' families, and gradually urge patients to correctly master their own diseases and obstacles, so that they can pay as much attention to their own problems in real life as possible.

H. Game activities: Game activities such as jigsaw puzzles and chess can be used to carry out targeted training for hemispatial agnosia, so that patients can gradually and correctly complete the game activities by guiding their attention.

In recent years, the attempts to treat unilateral spatial agnosia are as follows: ① Thermal stimulation: 1985+0985 Rubens reported for the first time that stimulating the left ear with cold water or the right ear with warm water can induce shock to the right eye and also shock to the left eye. In this way, the symptoms of unilateral spatial agnosia have been improved. Later, it was reported by CappaVallarRode and other scholars. ② Stimulate visual movement: induce nystagmus through visual movement, and improve unilateral spatial agnosia. PizzamiglioL reported in 1990 that moving parallel lines at equal intervals in one direction can induce optokinetic nystagmus, and by inducing slow-phase nystagmus to the left eye, unilateral spatial agnosia can be improved. ③ Wearing prism: the role of prism is to move the contralateral visual field to the middle, and it is reported that the visual perception activity of patients has been significantly improved after wearing it for four weeks. ④ Eye patch: Wearing eye patch on the healthy side or stimulating the agnostic side at the same time can achieve beneficial effects. ⑤ Video feedback method: By observing one's own activities, it is suggested to install a mirror in some relatively dangerous workplaces (such as kitchen) to reflect the agnosia on the left side to the right side, so that patients can pay attention to it and avoid burns.

(2) Gerstmann syndrome: including four aspects:

1) Left and right agnosia: Therapists often provide left and right clues to help patients identify objects on his left or right during treatment; Mark both sides of clothes, shoes, etc. Use different ribbons; When doing homework, shout out the left or right direction accordingly; Additional tactile or proprioception stimulation should be applied to the selected hand, such as tying a weight belt on the right wrist to help the patient distinguish. It is not appropriate to change after selecting one party.

2) Finger agnosia: Give tactile stimulation to the patient's fingers, and shout the name of the hand at the same time, repeatedly on different fingers.

3) Calculation error: provide patients with some numbers, start with the pen calculation of unit numbers, and then gradually increase the calculation difficulty; After that, the patient can be assigned homework that can automatically appear numbers, so that he can know and be familiar with numbers, such as playing cards and throwing dice, so as to train the patient's digital perception ability, improve his mental arithmetic ability and improve his digital alexia.

4) agraphia: assist patients in writing and tell them the meaning of writing materials. If it is possible for healthy limbs to write, it is necessary to focus on training healthy limbs' ability in this respect.

(3) Disease agnosia: It is difficult to treat, and should be reminded and monitored frequently, but the symptoms usually heal themselves within 3~6 months.

(4) Structural apraxia: For patients with structural apraxia, we can ask them to repeat simple copying or imitation exercises. For patients with left hemisphere injury, marked copying or imitation exercises can be used, from simple graphics to the topic of decreasing symbols, and then from plane graphics to complex graphics of three-dimensional graphics. For patients with right hemisphere injury, simple words or figures can be used for copying or imitation training, and then gradually develop into complex figures. Other treatment measures are

1) Building block exercise: You can do exercises with building blocks, imitate and build figures according to the model given by the therapist, and gradually increase the number from 2 to 3 blocks, from simple combination to complex combination, or from the level of plane combination to the level of three-dimensional combination.

2) Matchstick puzzle training: using matchsticks, according to the graphic imitation given by the therapist, starting from the puzzle of 2 ~ 3 matchsticks, gradually transitioning to complex graphics.

3) Training of wooden nails: According to the model given by the therapist, wooden nails can be used to imitate and construct graphics.

4) Training of transforming the plane pattern into a three-dimensional structure: this is the training of prompting the plane pattern drawn on paper to the patient, so that the patient can form a three-dimensional structure by using the combination of wood blocks or wooden nails.

5) Puzzle training: Divide the pattern drawn on the chessboard into several blocks, and combine the disordered blocks into pattern training.

6) Puzzle training: It is best to use simple puzzles sold in the market for training. The content is simple and closely related to daily life. Too complicated will lead to confusion of patients. It should be noted that only after the patient can complete the subject well can he develop into the training of more difficult subjects.

(5) apraxia: Because it is difficult to complete fine movements, we should strengthen the practice of fine movements, give a lot of suggestive reminders during the practice or reduce suggestive reminders after the therapist guides the patient to improve, and increase the difficulty of activities.

(6) Dressing apraxia: The training of dressing apraxia is an important training item in occupational therapy. Therapists should fully understand the patient's past dressing habits, try to find out the dressing methods similar to those before the patient's onset, establish specific steps, and practice repeatedly according to the determined steps every day until the patient masters them. Therapists should teach patients to recognize the left, right, front, back and inside of clothes, and mark left, right, front, back and inside when necessary. If the patient can't button it correctly, instruct the patient to button it from the bottom button until the last button can dye the bottom button and buttonhole in a special color, so that when the patient realizes that it is difficult to button it, instruct the patient to hold the button with his fingers through the buttonhole and feel the feeling of buttonhole with his fingers.

According to the specific situation of patients, language can be used effectively in dressing change training, and attention should be paid to the influence of environmental factors on dressing change, and videos can also be used to help training.

Patients with clothing apraxia are often accompanied by unilateral spatial agnosia and unilateral structural agnosia, which can be referred to the treatment of unilateral spatial agnosia

4. Cognitive impairment has many manifestations. This paper mainly introduces the treatment of attention memory and thinking disorder.

(1) Attention disorder: Although attention disorder is only one aspect of cognitive impairment, its rehabilitation is the central issue of cognitive rehabilitation. Only by correcting attention disorder, memory, learning, communication and solving problems can we effectively carry out the rehabilitation of cognitive impairment.

Principles to be followed in training:

A. Before each training, when giving passwords, prompting information or changing activities, make sure that the patient has paid attention, and if possible, ask the patient to repeat what he just said.

B. In colorful life activities, more functional activity therapy should be adopted to improve attention and resilience.

C in training, the concept that the application environment will affect the execution of activities should be avoided. Treatment should be carried out in a quiet environment that will not cause distraction, and gradually transferred to a normal environment. When working with patients with brain injury, interference should be strictly limited to a minimum. For example, only a few people are allowed to be with him at first, and after a certain period of time, one person can also carry out treatment activities. If possible, activities can be arranged in your own room to minimize environmental changes.

D. When patients pay attention to improvement, gradually increase the treatment time and task difficulty, so as to teach patients to actively observe the surrounding environment, identify the factors that cause potential mental inattention, and eliminate or change the location, such as the location of TV and radio or open doors.

Emphasize the completion of each step in the sequence of activities and explain the reasons accurately.

F. Work with patients and their families to set goals, implement training plans, encourage family caregivers to participate in training, make them understand patients' situation and nursing skills, and encourage them to use the skills learned in training to urge patients during non-treatment time.

G. While paying attention to training, we should give consideration to and effectively deal with the rehabilitation of other cognitive disorders, such as memory, orientation, judgment and executive function.

2) Training methods:

A. information flow training:

A interest method: discover interesting things of patients and stimulate their attention with familiar activities, such as using computer games. At the beginning of the picture, the monkey is playing under a leafy tree. When patients pay attention and are interested, they gradually go deep into novel and complicated scenes and let them operate by themselves. Before they master it, don't easily expand the stimulus. Pay attention to observe whether there is mental fatigue during training.

B demonstration method: demonstrate the activities you want patients to do, use language prompts, and show the activities to be done in a variety of sensory ways, which will help patients understand the information you want them to pay attention to, such as playing Tai Ji Chuan, and at the same time let patients see the smooth movements of combining rigidity with softness, and at the same time explain the essentials of the movements rhythmically, so that patients' vision and hearing can be mobilized and their attention can be strengthened.

C. Reward method: use verbal praise or other intensive stimulation to increase the frequency and duration of expected attention behavior, and reward it immediately after the expected attention response appears. Therefore, in cognitive training such as attention, therapists can prepare some dolls, chocolates and various cartoon patches as small prizes to stimulate patients' enthusiasm.

D. Token method: This is also a reward method for the trainer to record whether the patient pays attention to the treatment task in a simple way every two minutes during the 30-minute treatment, and then use the token method in the treatment, and give tokens as long as the patient can pay attention to the treatment. The number of tokens that patients get in each treatment is very important.