There are no silly questions!
For the first one, I think the key distinction here is that we are avoiding PROM as a treatment goal, but not abandoning joint health all together. We should avoid any type of aggressive, end-range, repetitive passive range of motion because it can trigger sympathetic storms (increased heartrate, increased BP, increased ICP), increased spasticity, increased reflexive tone response, provide non-meaningful sensory input that doesn’t promote recovery. Even in Ranchos Peds V. Instead, use positioning, slow low-load movements, splinting, casting, and early HO monitoring techniques. Forceful and/or repetitive PROM can actually worsen HO risk (microtrauma, inflammation in already damaged tissue, heightened neuroinflammatory response).
Unfortunately kids can stall and stop progressing. Some may plateau for a while and then continue progressing. For those that get stuck and stay stuck, we then move from recovery mode to protection and participation mode. We education the family how to safely care for their child at the level they are at. If this is a higher Ranchos level (lower functional level), we need to teach them how to safely protect their child’s joints, understand how to protect their sensory system, safely position their child for function, and give their child the best quality of life possible. If the child is able to participate, we need to figure out how to maximize participation and safety. It is all about figuring out what the child’s brain can safely tolerate and working within those parameters.