(Longer unpolished/unfinished version) Use of Role-Playing Games (RPG) in All Formats (Tabletop, Live-Action (LARP), Choose Your Own Adventure (CYOA), and Computer-based) in the Treatment of Brain Injury.

Abstract

A presentation at Eastern Washington University, for the "People With Disabilities" Therapeutic Recreation course under the instruction Professor Emily Messina, this was the presentation portion of the course assignment.
This is the longer version of the essay associated with the presentation slide show on this topic, it is less polished and unfinished, but has far more detailed information, especially associated potential WHO ICD / ICF codes to take into consideration.

Full text

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RCLS-245
Therapeutic Recreation for People with Disabilities
W.A. Hawkes-Robinson
March 9th, 2013
Final Project Paper
“Hypothetical Therapeutic Recreation for Clients with Traumatic Brain Injury Using Role-Playing
Games as Therapy”
A hypothetical client with traumatic brain injury and multiple functional impairments submitted for
recreational therapy treatment using role-playing games as the chosen activity.
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Table of Contents
Checklist.........................................................................................................4
Overview.........................................................................................................9
Personal Experiences Related to Diagnosis - TBI.................................10
Personal Experience Related to the Interventions - Role-playing games
...............................................................................................................10
Diagnosis.......................................................................................................11
Body Functions......................................................................................16
Recovery Stage 1............................................................................16
b110.3 – consciousness functions............................................16
b1100.3 – State of consciousness.....................................16
b1101.3 Continuity of consciousness...............................16
b1102.3 Quality of consciousness....................................16
b1140.4 orientation to time......................................................17
b1141.2 Orientation to place....................................................17
b1142.2 – Orientation to person..............................................17
b11420.1 – Orientation to self..........................................17
b11421.4 – Orientation to others......................................17
b11428.4 then b11428.2 – Orientation to person, other
specified (story, pretend scenario)....................................17
b117.1 Intellectual functions...................................................18
b126 Temperament and Personality Functions........................18
b1260.1 Extraversion........................................................18
b1261.2 Agreeableness.....................................................18
b1263.2 Psychic stability..................................................18
b1264.1 Openness to experience .....................................18
b130.3 to b130.2 Energy and drive functions..........................19
b1300.3 – Energy level.....................................................19
b1301.2 – Motivation.......................................................19
Specific Mental Functions (b140-b189)..................................19
b140 Attention functions..................................................19
b1400.2 Sustaining attention.....................................19
b144 Memory functions...................................................19
B1440.2 Short term memory.....................................20
B1441.3 Long term memory.....................................20
B1442.2 Retrieval of memory...................................20
b147 Psychomotor functions.....................................20
b1470 Psychomotor control.......................................20
b1471 Quality of psychomotor functions..................20
b156 Perceptual functions.........................................20
b1560 Auditory perception........................................20
b1564 tactile perception............................................21
b160 thought functions..............................................21
b1600 pace of thought...............................................21
b1601 form of thought...............................................21
b164 higher-level cognitive functions..............................21
b1640 abstraction......................................................21
b1643 cognitive flexibility........................................21
b1645 judgment................................................................21
b1646 problem-solving..............................................21
b167 mental functions of language..........................................21
b1670 reception of language.....................................22
b16700 reception of spoken language.......................22
b210 seeing functions (completely blind, all fully impaired
– total blindness)..............................................................22
b230 hearing functions – no function limits.....................22
b265 touch function .........................................................22
b270 sensory functions related to temperature and other
stimuli...............................................................................22
b2702 sensitivity to pressure.....................................22
Pain (b280-b289).....................................................................22
b280 sensation of pain......................................................22
b2800 generalized pain..............................................22
b2801 pain in body part.............................................23
b28010 pain in head and neck...................................23
b28013 pain in back..................................................23
b28014 pin in upper limb..........................................23
b2802 pain in multiple body parts.............................23
b310 voice functions (initially full impairment for
speech, but has random moaning sounds from pain) 23
b3100 production of voice.........................................23
b320 articulation functions (complete impairment).........23
Functions related to the digestive system (b510-b539)...........23
b510 ingestive functions...................................................23
b5100.3 sucking.........................................................24
b5101.3 biting............................................................24
b5102.4 chewing.......................................................24
b5103.4 manipulation of food in mouth....................24
b5104.1 salivation.....................................................24
b5105.2 swallowing...................................................24
b51050.2 oral swallowing..................................24
b525 defecation functions – no voluntary control ...........24
b5253.4 fecal continence...........................................24
Urinary functions (B610-b539)...............................................24
b620 urinary functions......................................................24
b6203.4 urination continence, inability to voluntarily
retain urine.................................................................25
b760 control of voluntary movement functions...............25
b7600.3 control of simple voluntary movements......25
b7601.4 control of complex voluntary movements...25
b7602.3 coordination of voluntary movements.........25
b7603.4 supportive functions of arm or leg..............25
Environmental Factors...........................................................................27
ICU Environment...........................................................................28
Non-ICU Hospital Environment ....................................................28
Long-term Care Facility Environment ..........................................28
At-home Care Environment ...........................................................28
Stage 2............................................................................................29
b110.3 – consciousness functions............................................29
b1100.3 – State of consciousness.....................................30
b1101.3 Continuity of consciousness...............................30
b1102.3 Quality of consciousness....................................30
b1140.4 orientation to time......................................................30
b1141.2 Orientation to place....................................................30
b1142.2 – Orientation to person..............................................30
b11420.1 – Orientation to self..........................................30
b11421.4 – Orientation to others......................................31
b11428.4 then b11428.2 – Orientation to person, other
specified (story, pretend scenario)....................................31
b117.1 Intellectual functions...................................................31
b126 Temperament and Personality Functions........................31
b1260.1 Extraversion........................................................31
b1261.2 Agreeableness.....................................................31
b1263.2 Psychic stability..................................................32
b1264.1 Openness to experience .....................................32
b130.3 to b130.2 Energy and drive functions..........................32
b1300.3 – energy level.....................................................32
b1301.2 – motivation........................................................32
Specific Mental Functions (b140-b189)..................................32
b210.0 seeing functions ...................................................33
Stage 3............................................................................................35
b110.3 – consciousness functions............................................35
b1100.3 – State of consciousness.....................................35
b1101.3 Continuity of consciousness...............................36
b1102.3 Quality of consciousness....................................36
b1140.4 orientation to time......................................................36
b1141.2 Orientation to place....................................................36
b1142.2 – Orientation to person..............................................36
b11420.1 – Orientation to self..........................................36
b11421.4 – Orientation to others......................................36
b11428.4 then b11428.2 – Orientation to person, other
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specified (story, pretend scenario)....................................37
b117.1 Intellectual functions...................................................37
b126 Temperament and Personality Functions........................37
b1260.1 Extraversion........................................................37
b1261.2 Agreeableness.....................................................37
b1263.2 Psychic stability..................................................37
b1264.1 Openness to experience .....................................38
b130.3 to b130.2 Energy and drive functions..........................38
b1300.3 – energy level.....................................................38
b1301.2 – motivation........................................................38
Specific Mental Functions (b140-b189)..................................38
Stage 4............................................................................................41
b110.3 – consciousness functions............................................41
b1100.3 – State of consciousness.....................................41
b1101.3 Continuity of consciousness...............................41
b1102.3 Quality of consciousness....................................42
b1140.4 orientation to time......................................................42
b1141.2 Orientation to place....................................................42
b1142.2 – Orientation to person..............................................42
b11420.1 – Orientation to self..........................................42
b11421.4 – Orientation to others......................................42
b11428.4 then b11428.2 – Orientation to person, other
specified (story, pretend scenario)....................................42
b117.1 Intellectual functions...................................................43
b126 Temperament and Personality Functions........................43
b1260.1 Extraversion........................................................43
b1261.2 Agreeableness.....................................................43
b1263.2 Psychic stability..................................................43
b1264.1 Openness to experience .....................................43
b130.3 to b130.2 Energy and drive functions..........................44
b1300.3 – energy level.....................................................44
b1301.2 – motivation........................................................44
Specific Mental Functions (b140-b189)..................................44
Activities and Participation...........................................................................47
Recovery Stage 1...................................................................................47
Stage 2............................................................................................50
Stage 3............................................................................................52
Stage 4............................................................................................54
Environmental Factors...........................................................................56
Stage 1............................................................................................56
Code.........................................................................................56
Code.........................................................................................56
Stage 2............................................................................................57
Code.........................................................................................57
Code.........................................................................................57
Stage 3............................................................................................57
Code.........................................................................................57
Code.........................................................................................58
Stage 4............................................................................................58
Code.........................................................................................58
Code.........................................................................................58
Applicable Therapeutic Recreation Interventions........................................59
TR Technique Overview: Role-playing Games for Clients With TBI...60
Three Kinds of Role-Playing Games for Different Needs..............60
What is Role-Playing Gaming........................................................61
Tabletop Role-Playing Gaming...............................................61
Example Preparation for Tabletop RPG Without
Modifications....................................................................62
Example Game Play for Tabletop RPG Without
Modifications....................................................................62
Computer-based Role-playing Games.....................................63
Example of Offline Computer-based RPG Without
Modifications....................................................................63
Example of Online Computer-based RPG Without
Modifications....................................................................63
Live-action Role-Playing - LARP...........................................63
Example of LARP Without Modifications.......................63
RPG Modifications for Client With TBI...............................................64
Intervention #1 - Tabletop RPG Modification - Choose Your Own
Adventure for Severe TBI-related impairments.............................64
Intervention #2 - Offline Computer-based RPG Use and
Modifications for Client With TBI.................................................65
Intervention #3 – Tabletop RPG for Wheelchair-bound TBI Client......67
Intervention #4 - LARP Use and Modifications for Client With TBI
........................................................................................................70
Potential references pieces to use:................................................................73
Additional References..................................................................................74
RPG Therapy Resources...............................................................................77
Additional Resources....................................................................................78
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Checklist - Checklist - Checklist
Checklist
Three papers to submit as three separate files:
1. Completed & Submitted - “Presentation on Diagnosis and Technique” (slide show or similar)
due by Saturday 11:59 pm
2. TODO - “ICF Write Up on Diagnosis” due by Monday 11:59 pm (really Sunday night)
3. TODO - “TR Technique Write Up” (relevant to diagnosis) due by Monday 11:59 pm (really
Sunday night)
======================================
Presentation Checklist
Presentation on diagnosis 100 points
5 minute presentation should cover:
Brief overview of your diagnosis
Brief overview of your ICF write up
Brief overview of your chosen TR interventions
PowerPoint is not required, however presentation must include:
1. Visuals
2. Bulleted points
3. Creativity!
===========================
Diagnostic Checklist
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Checklist - Checklist - Checklist
Discussion of diagnosis 200 points
o At least a full page, double spaced, Times New Roman, Font Size 12, 1 inch margins
o Must cover
content from book Diagnoses section
at least three outside sources (can be a reputable website)
MUST use APA in-text citations AND reference page
List and describe ICF codes relevant to the diagnosis.
o Must include
At least three ICF codes from Function section (b codes)
At least three ICF codes from the Activities and Participation section (d codes)
At least two ICF codes from the Environmental Factors section (e codes)
o State the code
o Describe the code
o Discuss why you think this code is relevant to the diagnosis
** DON’T FORGET A REFERENCE PAGE using APA format!!! **
------------------------------------------
Headings for the ICF Write-Up Assignment should look as follows:
Diagnosis
(describe diagnosis here – AT LEAST A FULL PAGE)
Body Functions
Code and Name (ex. b710 Mobility of Joint Functions)
(describe the code here)
Discussion of Relevancy to Diagnosis
(discuss why you think the code is relevant to the diagnosis here)
Code and Name (ex. b710 Mobility of Joint Functions)
(describe the code here)
Discussion of Relevancy to Diagnosis
(discuss why you think the code is relevant to the diagnosis here)
Code and Name (ex. b710 Mobility of Joint Functions)
(describe the code here)
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Checklist - Checklist - Checklist
Discussion of Relevancy to Diagnosis
(discuss why you think the code is relevant to the diagnosis here)
---------------------------------------
Activities and Participation
Code and Name (ex. d560 Drinking)
(describe the code here)
Discussion of Relevancy to Diagnosis
(discuss why you think the code is relevant to the diagnosis here)
Code and Name (ex. d560 Drinking)
(describe the code here)
Discussion of Relevancy to Diagnosis
(discuss why you think the code is relevant to the diagnosis here)
Code and Name (ex. d560 Drinking)
(describe the code here)
Discussion of Relevancy to Diagnosis
(discuss why you think the code is relevant to the diagnosis here)
-----------------------------
Environmental Factors
Code and Name (ex. e250 Sound)
(describe the code here)
Discussion of Relevancy to Diagnosis
(discuss why you think the code is relevant to the diagnosis here)
Code and Name (ex. e250 Sound)
(describe the code here)
Discussion of Relevancy to Diagnosis
(discuss why you think the code is relevant to the diagnosis here)
References
** DON’T FORGET A REFERENCE PAGE using APA format!!! **
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Checklist - Checklist - Checklist
========================
TR Technique
TR Technique Write-Up relevant to diagnosis 100 points
Describe at least two Therapeutic Recreation interventions that can be used with this diagnosis.
You can use the interventions listed in the diagnosis section, but must provide greater detail than what
is listed there.
Remember to cite your sources using BOTH APA in-text citations AND an APA Reference Page!
The following must be included for each intervention described:
Intervention
Description of intervention
Needs addressed by intervention
(This should include needs listed in your description of the diagnosis)
Common Settings
Equipment Needed
Program Adaptations
(This should include any adaptations to the intervention that can be made based on the needs
of the clients participating)
Examples of intervention
Find two real-life programs for each intervention.
List the following for each:
Program Name
Location
Description of clients served
Qualifications of program facilitator
How you located it
** DON’T FORGET A REFERENCE PAGE using APA format!!! **
-------------------------------------------------
Headings for the TR Technique Write-Up should look as follows:
Intervention #1
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Checklist - Checklist - Checklist
Description of intervention
Needs addressed by intervention
Common Settings
Equipment Needed
Program Adaptations
Examples of intervention
Program One
Program Name
Location
Description of clients served
Qualifications of program facilitator
How you located it
Program Two
Program Name
Location
Description of clients served
Qualifications of program facilitator
How you located it
--------------------------------------
Intervention #2
Description of intervention
Needs addressed by intervention
Common Settings
Equipment Needed
Program Adaptations
Examples of intervention
Program One
Program Name
Location
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Checklist - Checklist - Checklist
Description of clients served
Qualifications of program facilitator
How you located it
Program Two
Program Name
Location
Description of clients served
Qualifications of program facilitator
How you located it
References
*Don’t forget to cite your sources using APA format!
Overview
In this hypothetical scenario, the client has significant impairment from Traumatic Brain Injury
(TBI). The client will progress through varioous stages from comatose, to self-sufficiency. While other
treatment and therapies are assumed to be undertaken, this document will focus on the use of
therapeutic recreational techniques in treating the client, specifically using variants of role-playing
games, with various modifications as warranted to fit specific client needs, throughout different stages
of impairment and recovery. The ultimate goal being to restore the client's functioning to as close to
pre-injury capabilities as possible. This does not necessarily mean the client will be able to perform the
same functions in the same way as pre-injury, but that modifications can be made, and skills developed,
that allow the client to compensate for any remaining permanent impairment, and still function
effectively in an autonomous “real life” setting, with a high rating of life satisfaction.
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Overview - Personal Experiences Related to Diagnosis - TBI - Personal Experiences Related to
Personal Experiences Related to Diagnosis - TBI
~1990 - When working as CNA & LPN in training at Doxie Hatch long term medical facility in
Murray, Utah, several patients were in comas, had severe paralysis, and other serious impairments.
~1990 - When worked at Hillcrest Care Center in Sandy, Utah, worked with various levels of special
needs, including some that had been fully functional prior to TBI from skiing and similar injuries
causing permanent impairments.
August 22nd, 2007 my mother had an incident that caused brain damage due to lack of oxygen for 12-
14 minutes, and I was closely involved during her initial recovery process (1 in 10,000 chance).
200x – Hippotherapy
Personal Experience Related to the Interventions - Role-playing games
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Diagnosis - Diagnosis - Diagnosis
Diagnosis
Client was involved in an accident and received multiple injuries to various parts of the brain
(and body). For the purposes of this document we will mostly focus on the Traumatic Brain Injury
(TBI) in this scenario. The accident was related to a high velocity recreational activity (skiing, skating,
snowboarding, skateboarding, surfing, biking, etc.).
Client was wearing a standard issue helmet appropriate for the activity, but helmet was severely
damaged during impact. Though the helmet likely saved the client's life, it was not sufficient to protect
completely against object piercings, depressed skull fractures, and coup-countercoup injury of the
brain. The TBI includes diffuse injury, and some localized concussive and piercing injuries to specific
parts of the brain.
Due to the nature and severity of the injuries, EMT personnel induced coma on site. After
arriving at the hospital, foreign objects (rock material) were removed from the skull, and depressed
skull fragments were surgically repaired. Some of the skull was temporarily removed to relieve
pressure from extreme swelling (edema). Client has remained in an induced coma for several days
while surgeries were performed. As swelling reduced, the skull was surgically repaired, and client was
removed from induced coma. A few more days transpired before the client regained consciousness.
It is suspected that the frontal lobes received primary focal (localized) acceleration-deceleration
injury, the brain stem experienced shearing, and the occipital lobe received coup-countercoup
secondary focal acceleration-deceleration injuries. Also the upper frontal and parietal lobes, along the
precentral gyrus and postcentral gyrus, received some puncture injuries from a sharply pointed rock on
the ground where head impacted, causing both a depressed skull fracture, and direct piercing of the
upper hemisphere, though this damage was relatively shallow. This may mean the client will have
functional impairment in initiation of voluntary movement (precentral gyrus), and also potentially loss
of tactile information (postcentral gyrus – primary somatosensory cortex). Since the structures are
mostly intact, the prognosis is currently hopeful that these areas will (mostly) return to normal original
functioning, though potentially some lingering functional impairment may be indicated.
As is common with this type of injury, and based on the Rancho stages of functioning, the client
is experiencing Post Traumatic Amnesia (PTA) causing both anterograde impairment of memories after
the TBI incident, and retrograde PTA impairment of memories before the TBI incident ((Porter, 143).
The prognosis is that this will likely improve over time as swelling reduces, and the the client
undertakes activities to encourage the brain to repair, or reroute functions as needed.
At time of the injury, the client was 20 years old , healthy, and active, with no prior conditions.
The client has not shown any unexpected significant complications from infection.
It is not believed that the client experienced anoxic (oxygen deprivation) or hypoxic (reduced
oxygen) brain injuries. The client did have multiple hematomas. An epidural hematoma (between the
skull and the dura of the brain) to the frontal lobe, a subdural hematoma to the upper brain caused by
foreign object penetration and depressed skull fracture, and an intracerebral hematoma near the base of
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Diagnosis - Diagnosis - Diagnosis
the brain caused by shearing forces. Multiple strategies, including surgeries, were implemented to
relieve pressure and control bleeding. Extensive therapeutic services will be necessary to help the client
return to as close to original functioning as possible, but it is likely there will be at least some lasting
impairment to multiple functions.
The brain experienced significant edema (swelling of the brain), a significant portion of the
skull was surgically removed to relieve pressure during the first three days after the trauma.
During the first 6 days, the client rating on the Glasgow Coma Scale (GCS) was less than 8
(severe brain injury, client in a coma). The first 3 days of this coma were medically induced. It took an
additional 3 days for the client to pull out of the coma after medically induced coma induction
procedures were discontinued.
The client's initial functional level when RT is introduced to the case, is just coming out of an induced
coma, with minimal interactive capacity.
The client's stamina is currently limited to durations around 15-30 minutes between extended hours of
rest.
Current swelling due to concussive injury at occipital lobe causing complete visual impairment,
prognosis is hopeful that this may be temporary.
Client does not appear to have any hearing impairment.
Client appears to understand speech and (initially) simple directives.
Client is daily showing improving signs of comprehending increasingly complex directives.
Client shows indications of memory impairment both from past long-term memory, and the ability to
incorporate new short term memories into new long term memory, prognosis hopeful that this is
temporary.
Client shows indications of periodic disorientation and/or frustration.
Client is clearly in significant pain, requiring very short therapeutic periods, and significant pain
medication.
Client can comprehend and respond to simple yes/no (binary) questions via hand squeeze and/or eye-
blink.
Applicable codes.
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Diagnosis - Diagnosis - Diagnosis
TBI is caused by direct traumatic injury to the brain. The injury can be concussive or piercing. An
example of a concussive injury could be caused by a fall from bicycle, motorcycle, or horse, and the
head striking the ground. Even with a helmet, a secondary concussive injury can incur internally as the
a portion of the brain impacts and compresses against the inside of the skull, and can have secondary
collisions. Another concussive type can occur from an object striking the skull, such as a ball, baseball
bat, rock, or from explosions in the area.
Brain injuries can be specific or diffuse....
A car accident is an example of a common “diffuse brain injury”, compared to …........
A piercing injury actually penetrates the skull and the surface of the brain. Examples of
penetrating injuries include bullets from gunshot wounds, shrapnel from an explosion, a sharp object
like an ice pick, and the one of the most famous TBI's a tamping rod as in the case of Phineas Gage.
Different TBI's can cause cause specific regional functional impairment if localized to small areas, or
can cause many areas if a larger area, or multiple areas, of the brain received damaged.
TBI is to be differentiated from “head injury” by difference in the actual injury. An example of a head
injury would be a laceration of the forehead that does not penetrate the skull, nor have struck with
sufficient force to damage the skull or cause secondary concussive impact inside the skull with the
brain.
Alcohol was not a factor.
The client was wearing a standard helmet related to the activity (skiing, snowboarding, skating, biking)
From book, need to rewrite in own words: “during the initial weeks of inpatient rehability, the team
primarily focuses on restoration of skills through graduated tasks and repetition based on the theories
of brain plastiticy. The last weeks of the client's rehabilitation stay focused on transitioning the client
into his/her discharge envroment (e.g. community living program, at home with spouse). This includes
teaching the client and caregiver (as appropriate) compensatory strategies and techniques to facilitate
the recovery process post discharge.”
Rancho 1 (coma stage): no response to sound, sight, touch, or movement. Sensory stimulation may still
be used to possibly help brain plasticity, though it is not yet clear if this helps to improve cognitive
function at this state (Porter, p144).
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Diagnosis - Diagnosis - Diagnosis
For the sake of this document, short of reading stories to the client, since RPG is an interactive activity,
it would not be a usable intervention at this stage due the lack of ability for the client to respond and
interact with RT prompts.
Rancho II, III (low arousal stage):
Client has the beginnings of response to sensory stimuli. At this stage, the RT could begin to implement
the most rudimentary of RPGs, the Choose Your Own Adventure (CYOA) form. As long as the client
can make a binary/Boolean response indicated yes or no, whether verbally, by number of eye blinks,
hand squeeze, or other method.
The TR's goal is to provide one-step directions to the client, attempting to elicit controlled and
intentional responses.
The environment needs to be a quiet, minimally distracting setting.
Rancho IV, V, VI (post-traumatic amnesia stage): The client may still be experience amnesia,
frustration, agitation, and restless (p145).
Enviroment still quiet and minmal distractions.
Gradual improve cognitive processing for:
•Attention
•memory
•Orientation
Initially short sessions of only two 15 minute session per day, then gradually increase to single 30-
minute session daily.
“Modalities chosen reflect the client's interests to maximize attention, motivation, and willingness to
participate in the task.” (Porter, 2010)
Rancho VII, VIII (post-confusional stage):
Clients are more fully oriented on x3 (person, place, time). No longer agitated or restless.
Still problems with higher-level cognitive skills:
•Problem solving
•reasoning
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Diagnosis - Diagnosis - Diagnosis
•organizing
•planning
•referencing
•decision making
•overload easily (decompensation) under stress
TR undertakes graduated tasks with repetition, teaching compensatory skills and strategies to both the
client and family.
Emphasized:
•Integration training
•Family training
•Social skills training
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Diagnosis - Body Functions - Body Functions
Body Functions
Remember code, and qualifier
b1440.2 for example
0 = No impairment.
1 = Mild (5-24%)
2 = Moderate (25-49%)
3 = Severe (50-95)
4 = Complete (96-100%)
Recovery Stage 1
TBI includes diffuse injury, and some localized concussive and piercing injuries to specific parts of the
brain.
b110.3 – consciousness functions
The client's initial functional level when RT is introduced to the case, is just coming out of an induced
coma, with minimal interactive capacity.
The client's stamina is currently limited to durations around 15-30 minutes between extended hours of
rest.
Client is initially functioning at Ranchos Los Amigos Cognitive Levels II & III. Able to open eyes in
response to stimuli such as a spoken request or physical touch.
b1100.3 – State of consciousness
No longer in coma, but still lapsing in and out of consciousness, and is frequently in heavy stupor due
to injuries and medication.
b1101.3 Continuity of consciousness
Client's periods of consciousness are inconsistent and vary in duration.
Client has periods of consciousness lasting anywhere from 15 to 45 minutes, many times throughout
the day and night.
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Diagnosis - Body Functions - Recovery Stage 1
b1102.3 Quality of consciousness
Client is periodically wakeful, mildly alert, has some periodically aware sentience, but does fade in and
out of drug-induced and injury-induced altered states.
b1140.4 orientation to time
Initially the client generally does not know whether it is day or night, what time of day, the day, week,
month, year.
b1141.2 Orientation to place
The client generally realizes he/she is in the hospital, and even the ICU.
b1142.2 – Orientation to person
Client is generally aware of others, self, and some differentiation between different people. Client is
aware as to why he/she is in the hospital from an accident. There are periods of disorientation,
especially during the first few days out of the coma, but this is quickly improving.
b11420.1 – Orientation to self
Client is aware of self, remembers his/her name, knows current age, birth place, etc. Occasionally a
little foggy from the injury, and especially the medication.
b11421.4 – Orientation to others
Initially the client does not remember anyone. This starts to improve in a few days, but often requires
reminding the client who each person is, their name and relationship to the client. After a few days this
improves significantly to b11421.2.
b11428.4 then b11428.2 – Orientation to person, other specified (story, pretend
scenario)
Initially the client is too disoriented and has such significant memory impairment that using the
CYOA form of RPG is contraindicated, but after just a few days, the functioning is closer to b11428.2,
and within a week around b11428.1. This means the client is able to engage in “let's pretend” imaginary
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Diagnosis - Body Functions - Recovery Stage 1
scenarios and differentiate from the real and imagined situations. The client may need occasional
reminders, but is now potentially ready to begin the CYOA form of RPG TR treatment.
b117.1 Intellectual functions
Client has some initial intellectual impairment, but much of this clears up within only a few
days. No signs of dementia or long term mental retardation, though some specific cognitive
impairments as specified elsewhere.
b126 Temperament and Personality Functions
b1260.1 Extraversion
Client is mostly presenting, as best as possible under the conditions, a mostly outgoing, sociable
attitude towards others, clearly desiring interaction most of the time. Occasionally, due to pain and
medication, and initial temporary disorientation, prefers to be left alone.
b1261.2 Agreeableness
Initially the client is disoriented and agitated due to injury, pain, and medication. This quickly
subsides, and client is generally agreeable, cooperative, amicable, and accommodating. There are still
the occasional periods where the client is upset, resistant, and agitated, this is usually towards the end
of a waking cycle due to fatigue, or when feeling the pain and requesting another pain killer
application.
b1263.2 Psychic stability
Client is mostly even-tempered, calm, and composed. Only occasionally irritable, usually
towards end of waking period due to fatigue and pain.
b1264.1 Openness to experience
Client indicates willingness and openness to trying new experiences, and is willing to try the
CYOA for of TR RPG. Every now and then the client is resistant, when tired or hurting more, and
refuses to engage in new activities.
Page 18 of 78

Diagnosis - Body Functions - Recovery Stage 1
b130.3 to b130.2 Energy and drive functions
As is normal for such serious TBI (_____), client is very exhausted as well as heavily
medicated. As brain swelling continues to reduce, the body begins to flush all the stress chemicals, and
medication dosages can be reduced, the client's energy level, motivation, and periods of consciousness
increase.
b1300.3 – Energy level
As is normal for such serious TBI, client is very exhausted as well as heavily medicated. As
brain swelling continues to reduce, the body begins to flush all the stress chemicals, and medication
dosages can be reduced, the client's energy level increases. Initially the client is conscious or available
for activities for just 15 minutes or so, twice per day. This quickly improves to 30 minutes in a single
session per day.
b1301.2 – Motivation
The client is reasonably motivated under the circumstances, but periodically is lethargic, and
feeling unmotivated to participate in activities.
Specific Mental Functions (b140-b189)
b140 Attention functions
b1400.2 Sustaining attention
Initially the client is only able to focus and sustain focus of attention for up to 15 minutes at a
time, after that fatigue, pain, and medication make it very difficult for the client to continue to remain
focused. As time progresses this increases to 30 minutes, and even better with more recovery time in
later recovery stages.
b144 Memory functions
Page 19 of 78

Diagnosis - Body Functions - Recovery Stage 1
B1440.2 Short term memory
Initially client's short-term memory shows significant impairment, requiring repetition of
information frequently (every 5 to 10 minutes or so). Often losing retention of memory after 30
seconds. This quickly began to improve over the following recovery days.
B1441.3 Long term memory
Initially most of client's past long-term memory was impaired. And was unable to transfer new
information from short term memory into longer term memory. After a few days, this began to show
signs of improvement, though professions is a little slower.
B1442.2 Retrieval of memory
Initially client's long term memory recall was significantly impaired with significant amnesia.
This quickly began to recover as the other long term and short term memory functions improved as
well.
b156 Perceptual functions
b1560.0 Auditory perception
No impairment. Client can discern between different voices from different people, noises from
different objects, with accurate perception.
b1564.2 Tactile perception – right hand
Some tactile impairment to right hand. Client can sense contact, but has difficulty discerning
different textures, and delayed response reacting to contact.
b1564.3 Tactile perception – rest of body
Client initially had little-to-no tactile response throughout most of body due to parietal lobe
injury. This is slowly returning as client's recovery progresses.
b160 Thought functions
Page 20 of 78

Diagnosis - Body Functions - Recovery Stage 1
b1600.3 Pace of thought
Thought processes very slow, those interacting with client must be patient and allow client time
to process stimuli, information, decision making, etc.
b1601.1 Form of thought
Client's thoughts are mostly able to organize thoughts on simpler issues in a logical and orderly
pattern. The client I s aware of permanence of objects (people still exist when not speaking or holding
hand), that when someone touches his/her hand there is another (real) person in existence doing so, etc.
Occasionally, when fatigued towards end of stamina, or during the middle of the night, client's thinking
occasionally less logical, but usually passes quickly.
b164 higher-level cognitive functions
b1640 abstraction
b1643 cognitive flexibility
b1645 judgment
b1646 problem-solving
b167 mental functions of language
b1670 reception of language
Page 21 of 78

Diagnosis - Body Functions - Recovery Stage 1
b16700 reception of spoken language
b210 seeing functions (completely blind, all fully impaired – total blindness)
b230 hearing functions – no function limits.
b265 touch function
b270 sensory functions related to temperature and other stimuli
b2702 sensitivity to pressure
Pain (b280-b289)
b280 sensation of pain
b2800 generalized pain
b2801 pain in body part
Page 22 of 78

Diagnosis - Body Functions - Recovery Stage 1
b28010 pain in head and neck
b28013 pain in back
b28014 pin in upper limb
b2802 pain in multiple body parts
b310 voice functions (initially full impairment for speech, but has random moaning sounds from
pain)
b3100 production of voice
b320 articulation functions (complete impairment)
Once out of induced coma, client has normal autonomic cardiovascular functioning.
Once out of coma, client has normal autonomic and voluntary respiratory functioning, removed from
breathing assistance equipment.
Functions related to the digestive system (b510-b539)
b510 ingestive functions
b5100.3 sucking
Page 23 of 78

Diagnosis - Body Functions - Recovery Stage 1
b5101.3 biting
b5102.4 chewing
b5103.4 manipulation of food in mouth
b5104.1 salivation
b5105.2 swallowing
b51050.2 oral swallowing
On feeding tube.
b525 defecation functions – no voluntary control
b5253.4 fecal continence
Urinary functions (B610-b539)
b620 urinary functions
b6203.4 urination continence, inability to voluntarily retain urine
Page 24 of 78

Diagnosis - Body Functions - Recovery Stage 1
b760 control of voluntary movement functions
b7600.3 control of simple voluntary movements
b7601.4 control of complex voluntary movements
b7602.3 coordination of voluntary movements
b7603.4 supportive functions of arm or leg
Code – Diffuse concussive brain injury -
Code – Localized Concussive injury to occipital lobe
Current swelling due to concussive injury at occipital lobe causing complete visual impairment,
prognosis is hopeful that this may be temporary.
Code – no vision
Page 25 of 78

Diagnosis - Body Functions - Recovery Stage 1
Code – piercing injury to speech center -
Code – piercing injury to left of body motor center (right side of brain?)
Code - Complete paralysis
Code - except right hand squeeze
Code - and eye blink
Code – injury to T?-T? - complete paralysis ex
Code – injury to L3
Code - Client does not appear to have any hearing impairment.
Code - Client appears to understand speech
Code - and (initially) simple directives.
Code - Client can comprehend and respond to simple yes/no (binary) questions via hand
squeeze and/or eye-blink.
Code – but can't yet handle moderate to complex directives.
Client is daily showing improving signs of comprehending increasingly complex directives.
Code – memory impairments
Code – past long-term
Code – past short-term
Page 26 of 78

Diagnosis - Body Functions - Recovery Stage 1
Code – currently lacking ability to turn new memories into long-term
Client shows indications of memory impairment both from past long-term memory, and the
ability to incorporate new short term memories into new long term memory, prognosis hopeful that this
is temporary.
Code - Client shows indications of periodic disorientation
Code - and/or frustration.
Code - Client is clearly in significant pain,
Code – significant pain medication
Code – very limited 15-20 minute stamina requiring very short therapeutic periods
Environmental Factors
Client is initially in the Intensive Care Unit at a hospital, but will be later transitioned to regular
hospital care as client continues to improve. Eventually client will be transitioned to either a long-term
care facility, or if sufficiently recovered, sent home with an out-patient recovery program and
applicable resources.
ICU Environment
Page 27 of 78

Diagnosis - Environmental Factors - ICU Environment
Non-ICU Hospital Environment
Long-term Care Facility Environment
At-home Care Environment
Page 28 of 78

Diagnosis - Environmental Factors - At-home Care Environment
Stage 2
TBI includes diffuse injury, and some localized concussive and piercing injuries to specific parts of the
brain.
Client has regained full visual function (
Client has not regained most speech, only able to answer with simple monosyllabic words.
Client has extremely labile facial expressions.
Client has significant aphasia, and is continuing treatment with speech therapist. Long term prognosis
is uncertain, but hopeful.
Client only has limited motor function of right arm, hand, and fingers, with full sensory response.
Client is able to move head slightly left and right, or up and down.
Client stamina is about 30 minutes.
Though client's cognitive functioning is now higher, the client's ability to communicate is severely
limited.
b110.3 – consciousness functions
The client's initial functional level when RT is introduced to the case, is just coming out of an induced
coma, with minimal interactive capacity.
The client's stamina is currently limited to durations around 15-30 minutes between extended hours of
rest.
Client is initially functioning at Ranchos Los Amigos Cognitive Levels II & III. Able to open eyes in
response to stimuli such as a spoken request or physical touch.
Page 29 of 78

Diagnosis - Environmental Factors - Stage 2
b1100.3 – State of consciousness
No longer in coma, but still lapsing in and out of consciousness, and is frequently in heavy stupor due
to injuries and medication.
b1101.3 Continuity of consciousness
Client's periods of consciousness are inconsistent and vary in duration.
Client has periods of consciousness lasting anywhere from 15 to 45 minutes, many times throughout
the day and night.
b1102.3 Quality of consciousness
Client is periodically wakeful, mildly alert, has some periodically aware sentience, but does fade in and
out of drug-induced and injury-induced altered states.
b1140.4 orientation to time
Initially the client generally does not know whether it is day or night, what time of day, the day, week,
month, year.
b1141.2 Orientation to place
The client generally realizes he/she is in the hospital, and even the ICU.
b1142.2 – Orientation to person
Client is generally aware of others, self, and some differentiation between different people. Client is
aware as to why he/she is in the hospital from an accident. There are periods of disorientation,
especially during the first few days out of the coma, but this is quickly improving.
b11420.1 – Orientation to self
Client is aware of self, remembers his/her name, knows current age, birth place, etc. Occasionally a
little foggy from the injury, and especially the medication.
b11421.4 – Orientation to others
Initially the client does not remember anyone. This starts to improve in a few days, but often requires
Page 30 of 78

Diagnosis - Environmental Factors - Stage 2
reminding the client who each person is, their name and relationship to the client. After a few days this
improves significantly to b11421.2.
b11428.4 then b11428.2 – Orientation to person, other specified (story, pretend
scenario)
Initially the client is too disoriented and has such significant memory impairment that using the
CYOA form of RPG is contraindicated, but after just a few days, the functioning is closer to b11428.2,
and within a week around b11428.1. This means the client is able to engage in “let's pretend” imaginary
scenarios and differentiate from the real and imagined situations. The client may need occasional
reminders, but is now potentially ready to begin the CYOA form of RPG TR treatment.
b117.1 Intellectual functions
Client has some initial intellectual impairment, but much of this clears up within only a few
days. No signs of dementia or long term mental retardation, though some specific cognitive
impairments as specified elsewhere.
b126 Temperament and Personality Functions
b1260.1 Extraversion
Client is mostly presenting, as best as possible under the conditions, a mostly outgoing, sociable
attitude towards others, clearly desiring interaction most of the time. Occasionally, due to pain and
medication, and initial temporary disorientation, prefers to be left alone.
b1261.2 Agreeableness
Initially the client is disoriented and agitated due to injury, pain, and medication. This quickly
subsides, and client is generally agreeable, cooperative, amicable, and accommodating. There are still
the occasional periods where the client is upset, resistant, and agitated, this is usually towards the end
of a waking cycle due to fatigue, or when feeling the pain and requesting another pain killer
application.
Page 31 of 78

Diagnosis - Environmental Factors - Stage 2
b1263.2 Psychic stability
Client is mostly even-tempered, calm, and composed. Only occasionally irritable, usually
towards end of waking period due to fatigue and pain.
b1264.1 Openness to experience
Client indicates willingness and openness to trying new experiences, and is willing to try the
CYOA for of TR RPG. Every now and then the client is resistant, when tired or hurting more, and
refuses to engage in new activities.
b130.3 to b130.2 Energy and drive functions
As is normal for such serious TBI (_____), client is very exhausted as well as heavily
medicated. As brain swelling continues to reduce, the body begins to flush all the stress chemicals, and
medication dosages can be reduced, the client's energy level, motivation, and periods of consciousness
increase.
b1300.3 – energy level
As is normal for such serious TBI, client is very exhausted as well as heavily medicated. As
brain swelling continues to reduce, the body begins to flush all the stress chemicals, and medication
dosages can be reduced, the client's energy level increases. Initially the client is conscious or available
for activities for just 15 minutes or so, twice per day. This quickly improves to 30 minutes in a single
session per day.
b1301.2 – motivation
The client is reasonably motivated under the circumstances, but periodically is lethargic, and
feeling unmotivated to participate in activities.
Specific Mental Functions (b140-b189)
b140 attention functions
b1400 sustaining attention
b144 memory functions
Page 32 of 78

Diagnosis - Environmental Factors - Stage 2
b1440 short term memory
b1441 long term memory
b1442 retrieval of memory
b147 psychomotor functions
b1470 psychomotor control
b1471 quality of psychomotor functions
b156 perceptual functions
b1560 auditory perception
b1564 tactile perception
b160 thought functions
b1600 pace of thought
b1601 form of thought
b164 higher-level cognitive functions
b1640 abstraction
b1643 cognitive flexibility
b1645 judgment
b1646 problem-solving
b167 mental functions of language
b1670 reception of language
b16700 reception of spoken language
b210.0 seeing functions
Client has fully recovered from previous complete (blind) impairment (previously b210.4) that
had been observed during recovery stage 1.
b230 hearing functions – no function limits.
b265 touch function
b270 sensory functions related to temperature and other stimuli
b2702 sensitivity to pressure
Pain (b280-b289)
b280 sensation of pain
b2800 generalized pain
b2801 pain in body part
Page 33 of 78

Diagnosis - Environmental Factors - Stage 2
b28010 pain in head and neck
b28013 pain in back
b28014 pin in upper limb
b2802 pain in multiple body parts
b310 voice functions (initially full impairment for speech, but has random moaning sounds from pain)
b3100 production of voice
b320 articulation functions (complete impairment)
Once out of induced coma, client has normal autonomic cardiovascular functioning.
Once out of coma, client has normal autonomic and voluntary respiratory functioning, removed from
breathing assistance equipment.
B539 functions related to the digestive system (b510-b539)
b510 ingestive functions
b5100.3 sucking
b5101.3 biting
b5102.4 chewing
b5103.4 manipulation of food in mouth
b5104.1 salivation
b5105.2 swallowing
b51050.2 oral swallowing
On feeding tube.
b525 defecation functions – no voluntary control
b5253.4 fecal continence
Urinary functions (B610-b539)
b620 urinary functions
b6203.4 urination continence, inability to voluntarily retain urine
b760 control of voluntary movement functions
b7600.3 control of simple voluntary movements
b7601.4 control of complex voluntary movements
b7602.3 coordination of voluntary movements
b7603.4 supportive functions of arm or leg
Page 34 of 78

Diagnosis - Environmental Factors - Stage 2
Stage 3
Client has impairment around T1-T4, may be temporary.
Client has regained use of entire upper body.
Client can engage in light speech using very simple sentences, but still has some aphasia.
Client can not move legs.
Client has unpredictable control of bowels and bladder.
Client stamina has increased to about an hour for recreational activity capacity before needing rest.
Client affect is no longer labile.
TBI includes diffuse injury, and some localized concussive and piercing injuries to specific parts of the
brain.
b110.3 – consciousness functions
The client's initial functional level when RT is introduced to the case, is just coming out of an induced
coma, with minimal interactive capacity.
The client's stamina is currently limited to durations around 15-30 minutes between extended hours of
rest.
Client is initially functioning at Ranchos Los Amigos Cognitive Levels II & III. Able to open eyes in
response to stimuli such as a spoken request or physical touch.
b1100.3 – State of consciousness
No longer in coma, but still lapsing in and out of consciousness, and is frequently in heavy stupor due
to injuries and medication.
b1101.3 Continuity of consciousness
Client's periods of consciousness are inconsistent and vary in duration.
Client has periods of consciousness lasting anywhere from 15 to 45 minutes, many times throughout
the day and night.
Page 35 of 78

Diagnosis - Environmental Factors - Stage 3
b1102.3 Quality of consciousness
Client is periodically wakeful, mildly alert, has some periodically aware sentience, but does fade in and
out of drug-induced and injury-induced altered states.
b1140.4 orientation to time
Initially the client generally does not know whether it is day or night, what time of day, the day, week,
month, year.
b1141.2 Orientation to place
The client generally realizes he/she is in the hospital, and even the ICU.
b1142.2 – Orientation to person
Client is generally aware of others, self, and some differentiation between different people. Client is
aware as to why he/she is in the hospital from an accident. There are periods of disorientation,
especially during the first few days out of the coma, but this is quickly improving.
b11420.1 – Orientation to self
Client is aware of self, remembers his/her name, knows current age, birth place, etc. Occasionally a
little foggy from the injury, and especially the medication.
b11421.4 – Orientation to others
Initially the client does not remember anyone. This starts to improve in a few days, but often requires
reminding the client who each person is, their name and relationship to the client. After a few days this
improves significantly to b11421.2.
b11428.4 then b11428.2 – Orientation to person, other specified (story, pretend
scenario)
Initially the client is too disoriented and has such significant memory impairment that using the
CYOA form of RPG is contraindicated, but after just a few days, the functioning is closer to b11428.2,
and within a week around b11428.1. This means the client is able to engage in “let's pretend” imaginary
Page 36 of 78

Diagnosis - Environmental Factors - Stage 3
scenarios and differentiate from the real and imagined situations. The client may need occasional
reminders, but is now potentially ready to begin the CYOA form of RPG TR treatment.
b117.1 Intellectual functions
Client has some initial intellectual impairment, but much of this clears up within only a few
days. No signs of dementia or long term mental retardation, though some specific cognitive
impairments as specified elsewhere.
b126 Temperament and Personality Functions
b1260.1 Extraversion
Client is mostly presenting, as best as possible under the conditions, a mostly outgoing, sociable
attitude towards others, clearly desiring interaction most of the time. Occasionally, due to pain and
medication, and initial temporary disorientation, prefers to be left alone.
b1261.2 Agreeableness
Initially the client is disoriented and agitated due to injury, pain, and medication. This quickly
subsides, and client is generally agreeable, cooperative, amicable, and accommodating. There are still
the occasional periods where the client is upset, resistant, and agitated, this is usually towards the end
of a waking cycle due to fatigue, or when feeling the pain and requesting another pain killer
application.
b1263.2 Psychic stability
Client is mostly even-tempered, calm, and composed. Only occasionally irritable, usually
towards end of waking period due to fatigue and pain.
b1264.1 Openness to experience
Client indicates willingness and openness to trying new experiences, and is willing to try the
CYOA for of TR RPG. Every now and then the client is resistant, when tired or hurting more, and
refuses to engage in new activities.
Page 37 of 78

Diagnosis - Environmental Factors - Stage 3
b130.3 to b130.2 Energy and drive functions
As is normal for such serious TBI (_____), client is very exhausted as well as heavily
medicated. As brain swelling continues to reduce, the body begins to flush all the stress chemicals, and
medication dosages can be reduced, the client's energy level, motivation, and periods of consciousness
increase.
b1300.3 – energy level
As is normal for such serious TBI, client is very exhausted as well as heavily medicated. As
brain swelling continues to reduce, the body begins to flush all the stress chemicals, and medication
dosages can be reduced, the client's energy level increases. Initially the client is conscious or available
for activities for just 15 minutes or so, twice per day. This quickly improves to 30 minutes in a single
session per day.
b1301.2 – motivation
The client is reasonably motivated under the circumstances, but periodically is lethargic, and
feeling unmotivated to participate in activities.
Specific Mental Functions (b140-b189)
b140 attention functions
b1400 sustaining attention
b144 memory functions
b1440 short term memory
b1441 long term memory
b1442 retrieval of memory
b147 psychomotor functions
b1470 psychomotor control
b1471 quality of psychomotor functions
b156 perceptual functions
b1560 auditory perception
b1564 tactile perception
Page 38 of 78

Diagnosis - Environmental Factors - Stage 3
b160 thought functions
b1600 pace of thought
b1601 form of thought
b164 higher-level cognitive functions
b1640 abstraction
b1643 cognitive flexibility
b1645 judgment
b1646 problem-solving
b167 mental functions of language
b1670 reception of language
b16700 reception of spoken language
b210 seeing functions (completely blind, all fully impaired – total blindness)
b230 hearing functions – no function limits.
b265 touch function
b270 sensory functions related to temperature and other stimuli
b2702 sensitivity to pressure
Pain (b280-b289)
b280 sensation of pain
b2800 generalized pain
b2801 pain in body part
b28010 pain in head and neck
b28013 pain in back
b28014 pin in upper limb
b2802 pain in multiple body parts
b310 voice functions (initially full impairment for speech, but has random moaning sounds from pain)
b3100 production of voice
b320 articulation functions (complete impairment)
Once out of induced coma, client has normal autonomic cardiovascular functioning.
Once out of coma, client has normal autonomic and voluntary respiratory functioning, removed from
breathing assistance equipment.
Page 39 of 78

Diagnosis - Environmental Factors - Stage 3
B539 functions related to the digestive system (b510-b539)
b510 ingestive functions
b5100.3 sucking
b5101.3 biting
b5102.4 chewing
b5103.4 manipulation of food in mouth
b5104.1 salivation
b5105.2 swallowing
b51050.2 oral swallowing
On feeding tube.
b525 defecation functions – no voluntary control
b5253.4 fecal continence
Urinary functions (B610-b539)
b620 urinary functions
b6203.4 urination continence, inability to voluntarily retain urine
b760 control of voluntary movement functions
b7600.3 control of simple voluntary movements
b7601.4 control of complex voluntary movements
b7602.3 coordination of voluntary movements
b7603.4 supportive functions of arm or leg
Page 40 of 78

Diagnosis - Environmental Factors - Stage 3
Stage 4
L3 injury. Prognosis likely permanent.
Client has regained some ability to walk with assistance of support products (braces and crutches).
Client speech mostly recovered, but still occasional aphasia.
Client has improved from much of past amnesia, but still shows some continued loss of some past
memories.
Client no longer shows impairment to retaining new memories.
Client now able to control bodily functions without assistance from other people.
Relevant codes
TBI includes diffuse injury, and some localized concussive and piercing injuries to specific parts of the
brain.
b110.3 – consciousness functions
The client's initial functional level when RT is introduced to the case, is just coming out of an induced
coma, with minimal interactive capacity.
The client's stamina is currently limited to durations around 15-30 minutes between extended hours of
rest.
Client is initially functioning at Ranchos Los Amigos Cognitive Levels II & III. Able to open eyes in
response to stimuli such as a spoken request or physical touch.
b1100.3 – State of consciousness
No longer in coma, but still lapsing in and out of consciousness, and is frequently in heavy stupor due
to injuries and medication.
b1101.3 Continuity of consciousness
Client's periods of consciousness are inconsistent and vary in duration.
Client has periods of consciousness lasting anywhere from 15 to 45 minutes, many times throughout
the day and night.
Page 41 of 78

Diagnosis - Environmental Factors - Stage 4
b1102.3 Quality of consciousness
Client is periodically wakeful, mildly alert, has some periodically aware sentience, but does fade in and
out of drug-induced and injury-induced altered states.
b1140.4 orientation to time
Initially the client generally does not know whether it is day or night, what time of day, the day, week,
month, year.
b1141.2 Orientation to place
The client generally realizes he/she is in the hospital, and even the ICU.
b1142.2 – Orientation to person
Client is generally aware of others, self, and some differentiation between different people. Client is
aware as to why he/she is in the hospital from an accident. There are periods of disorientation,
especially during the first few days out of the coma, but this is quickly improving.
b11420.1 – Orientation to self
Client is aware of self, remembers his/her name, knows current age, birth place, etc. Occasionally a
little foggy from the injury, and especially the medication.
b11421.4 – Orientation to others
Initially the client does not remember anyone. This starts to improve in a few days, but often requires
reminding the client who each person is, their name and relationship to the client. After a few days this
improves significantly to b11421.2.
b11428.4 then b11428.2 – Orientation to person, other specified (story, pretend
scenario)
Initially the client is too disoriented and has such significant memory impairment that using the
CYOA form of RPG is contraindicated, but after just a few days, the functioning is closer to b11428.2,
and within a week around b11428.1. This means the client is able to engage in “let's pretend” imaginary
Page 42 of 78

Diagnosis - Environmental Factors - Stage 4
scenarios and differentiate from the real and imagined situations. The client may need occasional
reminders, but is now potentially ready to begin the CYOA form of RPG TR treatment.
b117.1 Intellectual functions
Client has some initial intellectual impairment, but much of this clears up within only a few
days. No signs of dementia or long term mental retardation, though some specific cognitive
impairments as specified elsewhere.
b126 Temperament and Personality Functions
b1260.1 Extraversion
Client is mostly presenting, as best as possible under the conditions, a mostly outgoing, sociable
attitude towards others, clearly desiring interaction most of the time. Occasionally, due to pain and
medication, and initial temporary disorientation, prefers to be left alone.
b1261.2 Agreeableness
Initially the client is disoriented and agitated due to injury, pain, and medication. This quickly
subsides, and client is generally agreeable, cooperative, amicable, and accommodating. There are still
the occasional periods where the client is upset, resistant, and agitated, this is usually towards the end
of a waking cycle due to fatigue, or when feeling the pain and requesting another pain killer
application.
b1263.2 Psychic stability
Client is mostly even-tempered, calm, and composed. Only occasionally irritable, usually
towards end of waking period due to fatigue and pain.
b1264.1 Openness to experience
Client indicates willingness and openness to trying new experiences, and is willing to try the
CYOA for of TR RPG. Every now and then the client is resistant, when tired or hurting more, and
refuses to engage in new activities.
Page 43 of 78

Diagnosis - Environmental Factors - Stage 4
b130.3 to b130.2 Energy and drive functions
As is normal for such serious TBI (_____), client is very exhausted as well as heavily
medicated. As brain swelling continues to reduce, the body begins to flush all the stress chemicals, and
medication dosages can be reduced, the client's energy level, motivation, and periods of consciousness
increase.
b1300.3 – energy level
As is normal for such serious TBI, client is very exhausted as well as heavily medicated. As
brain swelling continues to reduce, the body begins to flush all the stress chemicals, and medication
dosages can be reduced, the client's energy level increases. Initially the client is conscious or available
for activities for just 15 minutes or so, twice per day. This quickly improves to 30 minutes in a single
session per day.
b1301.2 – motivation
The client is reasonably motivated under the circumstances, but periodically is lethargic, and
feeling unmotivated to participate in activities.
Specific Mental Functions (b140-b189)
b140 attention functions
b1400 sustaining attention
b144 memory functions
b1440 short term memory
b1441 long term memory
b1442 retrieval of memory
b147 psychomotor functions
b1470 psychomotor control
b1471 quality of psychomotor functions
b156 perceptual functions
b1560 auditory perception
b1564 tactile perception
Page 44 of 78

Diagnosis - Environmental Factors - Stage 4
b160 thought functions
b1600 pace of thought
b1601 form of thought
b164 higher-level cognitive functions
b1640 abstraction
b1643 cognitive flexibility
b1645 judgment
b1646 problem-solving
b167 mental functions of language
b1670 reception of language
b16700 reception of spoken language
b210 seeing functions (completely blind, all fully impaired – total blindness)
b230 hearing functions – no function limits.
b265 touch function
b270 sensory functions related to temperature and other stimuli
b2702 sensitivity to pressure
Pain (b280-b289)
b280 sensation of pain
b2800 generalized pain
b2801 pain in body part
b28010 pain in head and neck
b28013 pain in back
b28014 pin in upper limb
b2802 pain in multiple body parts
b310 voice functions (initially full impairment for speech, but has random moaning sounds from pain)
b3100 production of voice
b320 articulation functions (complete impairment)
Once out of induced coma, client has normal autonomic cardiovascular functioning.
Once out of coma, client has normal autonomic and voluntary respiratory functioning, removed from
breathing assistance equipment.
Page 45 of 78

Diagnosis - Environmental Factors - Stage 4
B539 functions related to the digestive system (b510-b539)
b510 ingestive functions
b5100.3 sucking
b5101.3 biting
b5102.4 chewing
b5103.4 manipulation of food in mouth
b5104.1 salivation
b5105.2 swallowing
b51050.2 oral swallowing
On feeding tube.
b525 defecation functions – no voluntary control
b5253.4 fecal continence
Urinary functions (B610-b539)
b620 urinary functions
b6203.4 urination continence, inability to voluntarily retain urine
b760 control of voluntary movement functions
b7600.3 control of simple voluntary movements
b7601.4 control of complex voluntary movements
b7602.3 coordination of voluntary movements
b7603.4 supportive functions of arm or leg
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Diagnosis - Environmental Factors - Stage 4
Activities and Participation
NOTE: Though client had enjoyed and participated in RPG's, he/she did not do so constantly, so it is
not believed to be an “overlearned leisure skill”, so should be a reasonable activity for monitoring and
assessment of overall recovery (Porter, p 144).
Recovery Stage 1
E-codes, example e335+2, e310+1.
1st Qualifier - performance (required)
2nd qualifier - capacity without assistance (required)
3rd qualifier – capacity with assistance (optional)
4th qualifier – performance without assistance (optional)
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Activities and Participation - Recovery Stage 1 - Recovery Stage 1
Scoring: activity, activity limitations, capacity, participation, participation restrictions, performance,
assistance, environmental factors (EF).
CYOA TR RPG
Choose Your Own Adventure Therapeutic Recreation Role-playing Game modification.
After consultation with the family and care-takers, it is determined that prior to injury, one of the
client's favorite activities included various forms of role-playing games.
Client mostly preferred tabletop, but had dabbled with both computer-based and live-action forms.
As client slowly regains various levels of functioning, modified versions of RPG will be presented in
which the client may participate.
The RT asks the client, “Would you like to play a simple version of a role-playing game?”.
“Squeeze/blink once for yes, two for no.” Client indicates yes...
“This adventure is set in Chicago during the 'Roaring '20's'. It is a mystery-style adventure.”
Of course any genre/setting will work.
“You will have three characters you can choose from. I will first list the three options, then I will ask
you which one you prefer as I go through the list a second time. You will then indicate 'yes' when I
mention the character you want.”
“You may choose to play: 1. A Police Detective, 2. A Private Eye, 3. An Investigative Reporter.”
The RT states, “Would you like me to repeat that list again?” (yes/no)
“Have you decided which option to pick from those 3 choices?” (yes/no)
When the client indicates “yes” to being ready to choose, the RT states, “I will now repeat those three
choices. Squeeze once for yes when you hear the option you want.”
Client squeezed yes for “Private Eye”.
The RT reads, “You have chosen Private Eye, is that correct?” Client confirms with single
squeeze/blink.
The RT continues, “The story unfolds as follows. An old man has come to your office. His house has
been robbed of a family heirloom they have had for generations. The police have no leads, but he says
everyone knows that you, as the ace private detective that you are, can use alternate channels to find
things the police can't or won't....”
If client is continuing to be responsive to this form of modified RPG, and if it is deemed appropriate,
and as client's functional level continues to improve, the client's family, friends, and caretakers may be
able to engage the client in continuing the “adventure” when the RT is not around.
Potential benefits:
Basic cognition
Social interaction
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Activities and Participation - Recovery Stage 1 - Recovery Stage 1
Simple to moderate problem solving
Speech comprehension
Encourages brain plasticity
relevant codes.
Purposeful Sensory Experiences (d110-d129)
d115 Listening
d163 Thinking
d172 Calculating
May add simple mathematical problems as client recovery improves.
d175 Solving problems
d1750 solving simple problems
d1751 solving complex problems
d177 making decisions
d310 communicating with – receiving – spoken messages
d335 producing nonverbal messages
d3350. Producing body language (controlled hand squeeze or eye-blink in response to questions).
Page 49 of 78

Activities and Participation - Recovery Stage 1 - Recovery Stage 1
D440 Fine Hand Use
d4401 Grasping
d4403 releasing
Any hand grasp will work for the activity.
“Conditions due to brain impairment (e.g. stroke, brain injury): focus on the use of graduated fine hand
activities and repeition to develpp neural connections to promote fine hand use (neuroplasticity).”
(porter, p 293).
d920 Recreation and Leisure
d9200 Play
d9205 Socializing
Stage 2
Though client's cognitive functioning is now higher, the client's ability to communicate is severely
limited.
Based on client's current functioning, it is recommended to have the client try using a mouse (or Wii-
mote) to participate in an offline computer-based RPG that is turn-based rather than real-time.
The client is able to move and click both buttons on a mouse, can see the computer screen clearly, and
has enough cognitive functioning to interact in the game at a much higher level than before.
Based on client's current functioning, it is recommended to have the client try using a mouse (or Wii-
mote) to participate in an offline computer-based RPG that is turn-based rather than real-time.
The client is able to move and click both buttons on a mouse, can see the computer screen clearly, and
has enough cognitive functioning to interact in the game at a much higher level than before.
Page 50 of 78

Activities and Participation - Recovery Stage 1 - Stage 2
Potential benefits:
Gross movement of arm and hand.
Fine movement of (clicking) fingers.
General cognitive.
Problem solving.
Relevant codes.
Purposeful Sensory Experiences (d110-d129)
d115 Listening
d163 Thinking
d172 Calculating
May add simple mathematical problems as client recovery improves.
d175 Solving problems
d1750 solving simple problems
d1751 solving complex problems
d177 making decisions
d310 communicating with – receiving – spoken messages
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Activities and Participation - Recovery Stage 1 - Stage 2
d335 producing nonverbal messages
d3350. Producing body language (controlled hand squeeze or eye-blink in response to questions).
D440 Fine Hand Use
d4401 Grasping
d4403 releasing
Any hand grasp will work for the activity.
“Conditions due to brain impairment (e.g. stroke, brain injury): focus on the use of graduated fine hand
activities and repeition to develpp neural connections to promote fine hand use (neuroplasticity).”
(porter, p 293).
d920 Recreation and Leisure
d9200 Play
d9205 Socializing
Stage 3
Purposeful Sensory Experiences (d110-d129)
d115 Listening
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Activities and Participation - Recovery Stage 1 - Stage 3
d163 Thinking
d172 Calculating
May add simple mathematical problems as client recovery improves.
d175 Solving problems
d1750 solving simple problems
d1751 solving complex problems
d177 making decisions
d310 communicating with – receiving – spoken messages
d335 producing nonverbal messages
d3350. Producing body language (controlled hand squeeze or eye-blink in response to questions).
D440 Fine Hand Use
d4401 Grasping
d4403 releasing
Any hand grasp will work for the activity.
“Conditions due to brain impairment (e.g. stroke, brain injury): focus on the use of graduated fine hand
activities and repeition to develpp neural connections to promote fine hand use (neuroplasticity).”
(porter, p 293).
d920 Recreation and Leisure
d9200 Play
d9205 Socializing
Page 53 of 78

Activities and Participation - Recovery Stage 1 - Stage 3
Stage 4
Purposeful Sensory Experiences (d110-d129)
d115 Listening
d163 Thinking
d172 Calculating
May add simple mathematical problems as client recovery improves.
d175 Solving problems
d1750 solving simple problems
d1751 solving complex problems
d177 making decisions
d310 communicating with – receiving – spoken messages
Page 54 of 78

Activities and Participation - Recovery Stage 1 - Stage 4
d335 producing nonverbal messages
d3350. Producing body language (controlled hand squeeze or eye-blink in response to questions).
D440 Fine Hand Use
d4401 Grasping
d4403 releasing
Any hand grasp will work for the activity.
“Conditions due to brain impairment (e.g. stroke, brain injury): focus on the use of graduated fine hand
activities and repeition to develpp neural connections to promote fine hand use (neuroplasticity).”
(porter, p 293).
d920 Recreation and Leisure
d9200 Play
d9205 Socializing
Page 55 of 78

Activities and Participation - Recovery Stage 1 - Stage 4
Environmental Factors
Stage 1
Code
Code and Name (ex. e250 Sound)
(describe the code here)
Discussion of Relevancy to Diagnosis
(discuss why you think the code is relevant to the diagnosis here)
Code
Code and Name (ex. e250 Sound)
(describe the code here)
Discussion of Relevancy to Diagnosis
(discuss why you think the code is relevant to the diagnosis here)
Page 56 of 78

Activities and Participation - Environmental Factors - Stage 1
Stage 2
Code
Code and Name (ex. e250 Sound)
(describe the code here)
Discussion of Relevancy to Diagnosis
(discuss why you think the code is relevant to the diagnosis here)
Code
Code and Name (ex. e250 Sound)
(describe the code here)
Discussion of Relevancy to Diagnosis
(discuss why you think the code is relevant to the diagnosis here)
Stage 3
Code
Code and Name (ex. e250 Sound)
Page 57 of 78

Activities and Participation - Environmental Factors - Stage 3
(describe the code here)
Discussion of Relevancy to Diagnosis
(discuss why you think the code is relevant to the diagnosis here)
Code
Code and Name (ex. e250 Sound)
(describe the code here)
Discussion of Relevancy to Diagnosis
(discuss why you think the code is relevant to the diagnosis here)
Stage 4
Code
Code and Name (ex. e250 Sound)
(describe the code here)
Discussion of Relevancy to Diagnosis
(discuss why you think the code is relevant to the diagnosis here)
Code
Code and Name (ex. e250 Sound)
(describe the code here)
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Activities and Participation - Environmental Factors - Stage 4
Discussion of Relevancy to Diagnosis
(discuss why you think the code is relevant to the diagnosis here)
Applicable Therapeutic Recreation Interventions
Describe at least two Therapeutic Recreation interventions that can be used with this diagnosis.
You can use the interventions listed in the diagnosis section, but must provide greater detail than what
is listed there.
Remember to cite your sources using BOTH APA in-text citations AND an APA Reference Page!
Intervention
Description of intervention
Needs addressed by intervention
(This should include needs listed in your description of the diagnosis)
Common Settings
Equipment Needed
Page 59 of 78

Applicable Therapeutic Recreation Interventions - Applicable Therapeutic Recreation Interventions -
Program Adaptations
(This should include any adaptations to the intervention that can be made based on the needs
of the clients participating)
Examples of intervention
Find two real-life programs for each intervention.
List the following for each:
Program Name
Location
Description of clients served
Qualifications of program facilitator
How you located it
TR Technique Overview: Role-playing Games for Clients With TBI
Three Kinds of Role-Playing Games for Different Needs
Though there are nearly infinite variants possible, there are three main branches in approaching role-
playing games:
1. Tabletop Role-Playing Game (TRPG)
2. Computer-based RPG (CRPG) – offline and online
3. Live-Action Role-Playing (LARP)
In recent years there has been increasing blurring of the lines between the three as various groups mix
aspects from the others together, but the distinctions still remain.
Each type of role-playing gaming variant has pros and cons for different client needs. Tabletop and
computer-based allow people with some types of mobility issues to participate without any
modifications, while LARP may require some modifications. LARP addresses more physical therapies,
while computer-based and tabletop generally only address cognitive and fine motor skills. All variants,
except offline computer-based, address social skills.
Some of the pros and cons, possible uses, and caveats are addressed in more detail later in this
document.
Page 60 of 78

Applicable Therapeutic Recreation Interventions - TR Technique Overview: Role-playing Games for
Clients With TBI - Three Kinds of Role-Playing Games for Different Needs
What is Role-Playing Gaming
The definition of a Role-playing Game (RPG) actually varies somewhat depending on the
sources and biases of those providing the definition. The key aspects of role-playing games across all
modes for the sake of this document include:
•Assumption of a fictional or hypothetical role by the participant, often called the “character” or
“Player Character”, though these can sometimes be set in “realistic scenarios” especially for
educational and professional skill development.
•Development of the character.
•Shared narrative with other participants.
•Mostly cooperative interaction with other participants though some variants are competitive.
•Well established rules systems (unlike childhood “let's pretend” and improvisational drama).
•Well-defined representative techniques for description of actions and action resolution.
Tabletop Role-Playing Gaming
The original form of the activity now know as role-playing gaming (RPGing) originally
developed from tabletop war games. Evolving from systems like H.G. Wells' 1913 “Little Wars”, war
game participants decided to begin mixing fantasy elements with their medieval-style warfare system,
with the release of Gary Gygax's “Chainmail” medieval miniatures wargame system in 1971, including
a fantasy supplement. Next the participants began to develop favorite persona with specifications
detailing the individual rather than just an entire military unit. Later they began to focus on scenarios
increasingly smaller in scale, just a few figures, rather than hundreds or thousands represented, and
increasingly more specific information adding detail to each character. Finally in 1974, Gary Gygax,
Dave Arneson, and their fellow game players developed Dungeons & Dragons (D&D), the first
tabletop role-playing game (RPG).
Tabletop role-playing games (RPGs) are now available from many companies, for every genre
Page 61 of 78

Applicable Therapeutic Recreation Interventions - TR Technique Overview: Role-playing Games for
Clients With TBI - What is Role-Playing Gaming
and setting imaginable. If there has been a book or movie released that has some level of popular
following, odds are that someone has created and RPG system for those that wish to play in their
favorite setting. Every genre is covered from science fiction & fantasy, to horror, mysteries, modern
military, post-apocalyptic, U.S. Western, to biblical, and historical.
Tabletop RPGs are generally cooperative in play, do not involve physically acting out or
dressing up, and are usually just verbal in nature, with maybe some play aides to help keep track of
various factors. To represent randomness, dice or other means (such as random card drawing) are
typically used as part of the action resolution process. Play aides typically involve a writing utensil and
paper for keeping track of the player character's (PC's) key attributes and relevant information, maps,
“battle mats”, and miniatures to help keep track of the relative location of the characters and others
interacted with during more complex events.
There are generally two gamer roles for RPGs, the player, and the game master (GM). The title
for GM comes under many aliases including the original D&D Dungeon Master (DM), and other
variants from other systems including referee, narrator, storyteller, etc. The player's character also can
have a variety of titles based on different game systems approaches. D&D used the currently standard
player character (PC), while others systems might call them Hero, Adventurer, etc.
Example Preparation for Tabletop RPG Without Modifications
Example Game Play for Tabletop RPG Without Modifications
Computer-based Role-playing Games
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Applicable Therapeutic Recreation Interventions - TR Technique Overview: Role-playing Games for
Clients With TBI - What is Role-Playing Gaming
Example of Offline Computer-based RPG Without Modifications
Example of Online Computer-based RPG Without Modifications
Live-action Role-Playing - LARP
Example of LARP Without Modifications
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Applicable Therapeutic Recreation Interventions - RPG Modifications for Client With TBI - RPG
Modifications for Client With TBI
RPG Modifications for Client With TBI
Intervention #1 - Tabletop RPG Modification - Choose Your Own Adventure
for Severe TBI-related impairments
Stage 1 in Client Recovery Process.
Description of intervention
As client slowly regains various levels of functioning, modified versions of RPG will be presented in
which the client may participate.
The RT asks the client, “Would you like to play a simple version of a role-playing game?”.
“Squeeze/blink once for yes, two for no.” Client indicates yes...
Needs addressed by intervention
(This should include needs listed in your description of the diagnosis)
Common Settings
Equipment Needed – None, maybe a CYOA book, or prepared script.
Program Adaptations
Using hand squeeze or eye-blink with Boolean-only (yes/no) questions for the client to answer (one
squeeze/blink for yes, two squeezes/blinks for no).
(This should include any adaptations to the intervention that can be made based on the needs
of the clients participating)
Examples of intervention
Find two real-life programs for each intervention.
Page 64 of 78

Applicable Therapeutic Recreation Interventions - RPG Modifications for Client With TBI -
Intervention #1 - Tabletop RPG Modification - Choose Your Own Adventure for Severe TBI-related
TODO!!!!
List the following for each:
Program Name
TODO
Location
TODO
Description of clients served
TODO
Qualifications of program facilitator
TODO
How you located it
TODO
Intervention #2 - Offline Computer-based RPG Use and Modifications for
Client With TBI
Stage 2 of client recovery process.
Though client's cognitive functioning is now higher, the client's ability to communicate is severely
limited.
Based on client's current functioning, it is recommended to have the client try using a mouse (or Wii-
Page 65 of 78

Applicable Therapeutic Recreation Interventions - RPG Modifications for Client With TBI -
Intervention #2 - Offline Computer-based RPG Use and Modifications for Client With TBI
mote) to participate in an offline computer-based RPG that is turn-based rather than real-time.
The client is able to move and click both buttons on a mouse, can see the computer screen clearly, and
has enough cognitive functioning to interact in the game at a much higher level than before.
Gross movement of arm and hand.
Fine movement of (clicking) fingers.
General cognitive.
Problem solving.
Relevant codes
Intervention #2
Description of intervention
As client slowly regains various levels of functioning, modified versions of RPG will be presented in
which the client may participate.
Needs addressed by intervention
(This should include needs listed in your description of the diagnosis)
Common Settings
Equipment Needed –
Program Adaptations
(This should include any adaptations to the intervention that can be made based on the needs
of the clients participating)
Examples of intervention
Find two real-life programs for each intervention.
TODO!!!!
Page 66 of 78

Applicable Therapeutic Recreation Interventions - RPG Modifications for Client With TBI -
Intervention #2 - Offline Computer-based RPG Use and Modifications for Client With TBI
List the following for each:
Program Name
TODO
Location
TODO
Description of clients served
TODO
Qualifications of program facilitator
TODO
How you located it
TODO
Intervention #3 – Tabletop RPG for Wheelchair-bound TBI Client
Stage 3 in client recovery process.
Description of intervention
Client now able to participate with minimal modification in tabletop RPG.
Client using wheelchair.
Some assistance is necessary from other participants to be patient and assist as needed when client has
trouble communicating correct word or intention verbally.
Client is able to fully manipulate, read, and calculate dice rolls and simpler character variable
calculations, though may have some trouble with verbally expressing the result.
Page 67 of 78

Applicable Therapeutic Recreation Interventions - Intervention #3 – Tabletop RPG for Wheelchair-
bound TBI Client - Intervention #3 – Tabletop RPG for Wheelchair-bound TBI Client
The client is able to pick up and roll dice
The client can comprehend letters, rulebooks, dialog, and mildly complex scenario puzzles.
Only minor modifications are necessary for client to participate in this form of RPG.
The tabletop interaction with other players and the Game Master (GM) will need to operate at a slower
pace than “normal”, but client will be able to participate with the complete tabletop experience.
Client can handle and write on paper with pencil.
Client can engage in adventure dialog between GM and other players.
Client understands and communicates desired player-character (PC) actions and action resolution.
Client understands rules discussion and enforcement, though occasional repetition or clarification may
be necessary.
Client can increasingly engage in social interaction with other players and GM.
Client can have increasingly complex dialog with other players and GM for both “in game” and “out of
game” discussions.
Client can engage in cooperative play with shared narrative, and increasingly complex problem solving
through group interaction.
Relevant codes.
As client slowly regains various levels of functioning, modified versions of RPG will be presented in
which the client may participate.
Needs addressed by intervention
(This should include needs listed in your description of the diagnosis)
Common Settings
Equipment Needed –
Program Adaptations
(This should include any adaptations to the intervention that can be made based on the needs
of the clients participating)
Examples of intervention
Find two real-life programs for each intervention.
TODO!!!!
Page 68 of 78

Applicable Therapeutic Recreation Interventions - Intervention #3 – Tabletop RPG for Wheelchair-
bound TBI Client - Intervention #3 – Tabletop RPG for Wheelchair-bound TBI Client
List the following for each:
Program Name
TODO
Location
TODO
Description of clients served
TODO
Qualifications of program facilitator
TODO
How you located it
TODO
Potential benefits:
Reading and reading comprehension
Social skills
Cooperative play
Joint and individual complex problem solving
Speech
Listening and comprehension
Math
Many others....
Relevant codes.
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Applicable Therapeutic Recreation Interventions - Intervention #3 – Tabletop RPG for Wheelchair-
bound TBI Client - Intervention #3 – Tabletop RPG for Wheelchair-bound TBI Client
Intervention #4 - LARP Use and Modifications for Client With TBI
Stage 4 in client recovery process.
Client has some signs of “spastic” movement. Prognosis is positive if continue to engage in regular
physical activities, but client is averse to “regular” workout regimen or physical therapy.
Client may engage in Live-action Role-play (LARP) with wheelchair and/or with braces/crutches.
Client is willing to try LARP for physical regimen.
Client initially participates in controlled clinical setting with other “LARPers”.
Over time client may be able to participate in LARP activities outside of clinical setting.
Relevant codes.
Description of intervention
As client slowly regains various levels of functioning, modified versions of RPG will be presented in
which the client may participate.
Needs addressed by intervention
(This should include needs listed in your description of the diagnosis)
Common Settings
Equipment Needed –
Program Adaptations
(This should include any adaptations to the intervention that can be made based on the needs
of the clients participating)
Examples of intervention
Find two real-life programs for each intervention.
Page 70 of 78

Applicable Therapeutic Recreation Interventions - Intervention #3 – Tabletop RPG for Wheelchair-
bound TBI Client - Intervention #4 - LARP Use and Modifications for Client With TBI
TODO!!!!
List the following for each:
Program Name
TODO
Location
TODO
Description of clients served
TODO
Qualifications of program facilitator
TODO
How you located it
TODO
Summary
Through the use of role-playing games modified to fit the client's diverse needs, the client was able to
receive a broad range of benefits from a favored recreational activity that provided improvements to:
Cognition
Speech
Social Interaction
Mathematics and general problem solving
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Applicable Therapeutic Recreation Interventions - Intervention #3 – Tabletop RPG for Wheelchair-
bound TBI Client - Intervention #4 - LARP Use and Modifications for Client With TBI
Fine motor skills
Gross motor skills and balance.
Long list of potential benefits.
Written Assignment Policies: All written assignments are required to meet the following criteria:
TYPED in 12 POINT FONT
Stapled in the upper left-hand corner (folders, binders, etc. not accepted).
Double-spaced
Numbered pages, not including the cover sheet.
Have a cover sheet listing the following:
Course Number and Name
Student’s name
Date assignment is due
Assignment Title
MUST adhere to APA Publication Manuscript style, i.e., references, citing (direct and paraphrased
quotes, headings, etc.)
ICF Write-Up on diagnosis 200
TR Technique Write-Up relevant to diagnosis (two interventions) 100
Presentation on diagnosis and technique 100
Midterm Exam 200
Final Exam 200
Attendance and Participation 200
1000
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Applicable Therapeutic Recreation Interventions - Intervention #3 – Tabletop RPG for Wheelchair-
bound TBI Client - Intervention #4 - LARP Use and Modifications for Client With TBI
Potential references pieces to use:
Nonperiodical/Book
AuthorLname, A.A. (1994). Title of Work. Location:Publisher
Portion of nonperiodical/book
AuthorLname, A.A., & CoAuthorLname, B.B. (1994). Title of chapter. In A. Editor, B. Editor, & C.
Editor (Eds), Title of book (pp. Xxx-xxx). Location: Publisher.
Sort alphabetically by last name.
Appelcline, S. (2011). Designers & dragons: A history of the role-playing game industry. Swindon,
UK:Mongoose Publishing.
Austin, D.R. & Crawford, M.E. (2001). Therapeutic Recreation: An introduction (3rd Edition).
Needham Heights, MA: Allyn & Bacon.
Bowman, S.L. (2006). The functions of role-playing games: How participants create community, solve
problems and explore identity (2nd Printing 2010). Jefferson, NC: McFarland & Company.
Burlingame, J. & Blaschko, T.M. (2002). Assessment tools for recreational therapy and related fields
(3rd edition). Ravensdale, WA: Idyll Arbor.
Cordes, K.A. & Ibrahim, H.M. (2003). Applications in Recreation and Leisure:For today and the
future (3rd Edition). Boston: McGraw Hill.
Cover, J.G. (2010). The creation of narrative in tabletop role-playing games. Jefferson, NC: McFarland
& Company.
Jordan, D.J. (1999). Leadership in leisure services: Making a difference (2nd Edition). State College,
PA: Venture Publishing.
Porter, H.R., & Burlingame, J. (2010). Recreational therapy handbook of practice: ICF-based
diagnosis and treatment. Enumclaw, WA: Idyll Arbor.
Page 73 of 78

Potential references pieces to use: - Potential references pieces to use: - Potential references pieces to
use:
Tresca, M.J. (2011). The evolution of fantasy role-playing games. Jefferson, NC: McFarland &
Company.
Stumbo, J.S. & Peterson, C.A. (2009). Therapeutic recreation program design: Principles &
procedures (5th Edition). San Francisco: Pearson Benjamin Cummings.
Additional References
TBI Resources
(need to APA format correctly)
http://www.traumaticbraininjury.com/
Brain Injury Association of America
Viewer 20130208
http://www.biausa.org/
Centre for Neuro Skills
http://www.neuroskills.com/
Page 74 of 78

Additional References - Additional References - Additional References
Brainline.org
http://www.brainline.org/
Traumatic Brain Injury Resource Center
http://www.braininjuryresources.org/
National Resource Center for Traumatic Brain Injury
http://www.tbinrc.com/
Military.com TBI Resources
http://www.military.com/benefits/veterans-health-care/tbi-resources.html
Northeastern University
http://www.northeastern.edu/nutraumaticbraininjury/
Traumatic Brain Injury Resouces
http://tbiresources.com/
Phineas Gage – Smithsonian
http://www.smithsonianmag.com/history-archaeology/Phineas-Gage-Neurosciences-Most-Famous-
Patient.html
Ekso Skeleton
http://www.ctnow.com/topic/wgntv-ekso-skeleton-the-rehabilitation-institute-of-chicago-conducted-
study-of-the-ekso-skeleton-20120918,0,5565147.story
Researchers Use Wii Fit to Help Restore Soldier's Balance After Traumatic Brain Injury
http://phys.org/news193428846.html
Wii RPGs: http://www.1up.com/features/ten-best-wii-rpgs
Use of the Wii Fit as an Adjunct to
Page 75 of 78

Additional References - Additional References - Additional References
Balance Training for a Patient with
Chronic Traumatic Brain Injury:
Case Report
http://ptrehab.ucsf.edu/sites/ptrehab.ucsf.edu/files/documents/Use%20of%20the%20Wii%20Fit%20as
%20an%20Adjunct%20to%20Balance%20Training%20for%20a%20Patient%20with%20Chronic
%20Traumatic%20Brain%20Injury%20-%20Case%20Report.pdf
Virtual Reality (VR) systems provide
stimulated and multidimensional
environments where body movements
and object manipulation through
virtual space, in real time, are
congruent with opportunities in the
real world
http://jknj.moh.gov.my/jsm/day2/Free%20Paper/Free%20Paper%203/FP_3_1%20Using%20Virtual
%20Reality%20to%20Improve%20Cognition%20in%20Traumatic%20Brain%20Injury.pdf
CNS - Occipital Lobes
http://www.neuroskills.com/brain-injury/occipital-lobes.php
Traumatic Brain Injury: Hope Through Research
National Institute of Neurological Disorders and Stroke
http://www.ninds.nih.gov/disorders/tbi/detail_tbi.htm
Video Game-Based Therapy May Help Treat TBI
NRI – Neurologic Rehabilitation Institute at Brookhaven Hospital
http://www.traumaticbraininjury.net/video-game-based-therapy-may-help-treat-tbi/
Database of Recreation Therapy Articles
http://recreationtherapy.com/rt-articles/addrbook.cgi?LT=Z&Password=
New Game can Add Years to Your Life, says Fordham Grad who is Gaming Expert
http://fordhamnotes.blogspot.com/2012/07/new-game-can-add-years-to-your-life.html
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RPG Therapy Resources
Romach Israel
http://www.lance.co.il/
Photo Resources
How Necessary is it to wear a helmet, Skateboarder Coma
http://www.silverfishlongboarding.com/forum/longboarding-resources-q/174050-how-necessary-wear-
helmet-4.html
Helmets not optional
That shot is from early June 2008 while recovering from my crash on May 24.
In that crash, I lacerated my liver, annihilated my pelvis and went into a coma for a week. I spent the
next several months relearning the most basic things in life (how to chew, how to use a bathroom, who
my parents were, where I lived, etc.) During that time in the hospital, I spent a large part of it on death
watch because the doctors expected me to die. I was given my last rights (religious ceremony for those
about to die) at the age of 18, and turned 19 (June 14th) in the hospital while wearing a diaper.
I got f-ed up BAD, but still stand by the fact that my family and friends got hurt more. I scared the
bajesus out of my parents and brothers, terrified my girl friend and really freaked out all of my friends.
I got cards from people as far away as Portugal showing me that they cared.
Bad stuff happens, and when it does, everyone gets hurt. Show your family and friends that you care by
finding a comfortable helmet and wearing it when you go skating. Yeah, there are points where even I
don't pull a helmet on, but my rule is that if I am leaving a sidewalk and going further than I can throw
my skateboard, I always wear a lid.
Posted 02-04-2011 10:04 AM
NOVA Bombers
Kids of the Future
Virginia Tech
I took a BAD fall on 05/24/08 on Mount Baker in WA. I lapsed into a coma, lacerated my liver, and
badly broke my pelvis, etc. I was a hair's breadth from death on the mountain and again later in the
hospital. The rehab therapists had to teach me how to do everything again... everything.
I survived that crash because of my helmet. WEAR ONE and send your family and loved ones to the
hospital, not the morgue.
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RPG Therapy Resources - RPG Therapy Resources - RPG Therapy Resources
Clinicians in intesive care unit
http://upload.wikimedia.org/wikipedia/commons/c/c4/Clinicians_in_Intensive_Care_Unit.jpg
Brain controlled wheelchair:
http://www.instructables.com/id/Brain-Controlled-Wheelchair/
Spinal Cord Injury Levels - Functionality of L2 - S5 Spinal Cord Injury
http://www.apparelyzed.com/support/functionality/l1-s5.html
Additional Resources
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