Examples

Functional Mobility

• Prime salience with context, measurable goals, and props (when appropriate). Use the Transtheoretical Model of Change and Skill Acquisition Chart to determine how much assistance is needed for the patient when setting measurable goals. Examples may include the following: 

  1. Context. "Pretend that this cone and ball are ice cream, and we are taking in the groceries ... don't let the ice cream fall off."  

  2. Measurable goals. "X number of repetitions for transporting cones from point A to point B successfully within Y timeframe."  

  3. Props. upside-down cone with a ball on top as "ice cream."   

• Target subcomponents of walking such as stance control, limb swing, propulsion, and postural stability. But challenges postural stability effectively. This can be further error augmented with a weighted vest, balance beam, or uneven surfaces. Determine areas of need based on deficits and apply evidenced-based HIT.    

Upper Body Dressing (UBD)

• Prime intensity with functional mobility (stepping) practice. Essential performance skills needed: orientation/attention, initiation/sequencing/termination, problem-solving, object/material manipulation, grasp/reach, postural control, and balance.

Guidance. Most-to-least assistance using the backward chaining method to conserve time, focus on a strength-based approach (what the patient can do) and increase the patient's independence with subparts that they can complete.   

Assistance as needed. least to most unless the patient has decreased cognition, then most to least. 

Trial and error. Increase variability (different shirts, donning methods, positions)

Error augment. Increase variability, use wrist weights, more difficult clothing for donning, and more complex positions (standing vs. seated).  

Orientation. Use a sorting activity and have the patient identify the differences between types of clothing or parts of clothing. Have them use the affected upper extremity (if appropriate) to sort clothing from one place-holder (i.e., bins) to another.   

Guidance. Physical or verbal guidance through the task. As soon as possible, begin to wean off the assistance.   

Assistance as needed. Set a number for allowed errors of the same mistake. Then assist. It may be beneficial for this task to allow for fewer allowed errors  (i.e., 2-3 vs. 3-5).  

Trial and error. Increase variability with locomotion and dual-task training targeting divided attention, such as stepping and gathering clothing items when performing the orienting subpart via part practice. 

Error augment. Increase variability with locomotion and dual-task training targeting divided attention. Use more options for errors, such as multiple kinds of clothing or having patient-oriented type and position of clothing. Including stepping or standing to increase workload. 

Lower Body Dressing (LBD)

Prime intensity with functional mobility practice.

Guidance. Most-to-least assistance using the forward chaining method to conserve time, focus on a strength-based approach (what the patient can do), and increase the patient's independence with subparts that they can complete.   

Assistance as needed. Least to most unless the patient has decreased cognition, then most to least. 

Trial and error. Increase variability and the degrees of freedom (different shirts, donning methods, positions)

Error augment. Increase variability, Use different sequencing approaches, more difficult clothing for donning, and more complex positions (standing vs seated).   

Grocery Shopping

Depending on UE priority based on PREP2 scores, this intervention can be performed to target stepping or include the affected UE primarily. 

For grocery shopping intervention focusing primarily on stepping, 

Use a grocery cart to support postural stability. A harness system may be needed to support postural stability or stance via BWS, depending on the severity of the patient. Methods of challenging subcomponents of walking may include the following: Challenge stance control with reducing BWS. Challenge limb swing with ankle weight. Propulsion can be challenged by adding resistance (drag bag, weights in the cart). Postural stability can be challenged by including aspects of the intervention that remove hands for support (e.g., leaving the shopping cart and stepping around a busy store). Use balance beams, variable stepping, duel tasking, or uneven surfaces. 

If the hand is a priority,  

Use continue with high-intensity stepping practice and incorporate the hand for grabbing grocery items. Use therapy props that are appropriate for the patient's current reaching and grasping skills. If the patient is in the skill acquisition phase of grasping, use blocked practice between stepping and hand training. This could be thought of as gathering items at one part of the store and stepping to another section. Keep the heat up as much as possible.    

Guidance. It can be done via manual assistance or other creative means 

Assistance as needed. Least to most. 

Trial and error. Increase variability and use allotted error parameters. 

Error augment. Increase variability, wrist weight, ankle weight, drag bag, and balance beam.

Cleaning 

Cleaning can be performed either walking or standing. It can incorporate laundry-based activities, window wiping, table wiping, or picking up items off the floor. The methods for challenging performance skills needed for the IADL of cleaning are endless, and this program encourages OTs to use their creativity with all IADL tasks. Similar to other intensified IADLs, use the PREP2 to prioritize that hand, and if it is a high priority, use stacking blocked practice during skill acquisition phases as operationally defined within OT-based HIT definitions.   

Guidance. It can be done via manual assistance or other creative means 

Assistance as needed. Least to most. 

Trial and error. Increase variability and use allotted error parameters.

Error augment. Increase variability, wrist weight, ankle weight, drag bag, and balance beam.

Yard Work

Can be done in multiple ways, and the OT should use their creativity to ensure the tasks are patient-centered and target performance skills needed for skill acquisition. This task can be done to increase salience and specificity. Again, high-intensity stepping should be the primary focus of this IADL. For example, the patient could perform functional mobility in the context of pushing a lawn mower or hauling a wheelbarrow. The prop can be used to support postural stability, and the subcomponents of walking can be targeted or supported based on the skill acquisition chart and the current protocol for evidence-based HIT.

When the hand is a high priority based on PREP2 scores,

Use blocked or random practice depending on the skill acquisition of the task performed. Stacking blocked practice between stepping and upper extremity training can be a helpful means of increasing skill acquisition and maintaining intensity (i.e., mow the lawn for stepping, then pull the weeds for hand function). Use appropriate shapes and props depending on the patient's skill with the hand and refer to the OT-based HIT definitions for understanding the current skill level and when to progress. Increase variability as soon as possible based on the allotted error parameter.      

Guidance. It can be done via manual assistance or other creative means.

Assistance as needed. Least to most. 

Trial and error. Increase variability and use allotted error parameters. 

Error augment. Increase variability, wrist weight, ankle weight, drag bag, and balance beam.