Documentation Blurbs
1. Patient participated in graded therapeutic activity including fine and gross motor coordination, dynamic balance training in order to increase ADL/IADL independence, therapeutic exercise, work simplification, energy conservation techniques, patient and caregiver education as well as safety awareness.
2. Education continued with pt/caregiver focusing on ADL/self-care tasks with return demonstration and accuracy for positive results.
3. Patient was referred for skilled services secondary to decreased AROM, strength and balance, which impact the patient’s ability to perform bathing, toileting, dressing, functional mobility, necessary for ADL/IADLs. Prior to hospitalization, patient performed these tasks with mod I, however now requires… Therapy services are medically necessary to increase PROM and increase gross and fine motor coordination to perform self care tasks, balance re-training in order to perform functional mobility and IADLs within home environment, pt/caregiver education for safe transfers. Without intervention, patient is at risk of decreased I with ADL/IADLs with increased burden of care on caregivers as well as falls.
4. Patient is a 57 y/o female who was seen for an initial occupational therapy evaluation in which the following deficits were noted: decreased BUE AROM, UE strength, GM coordination/skills, functional activity tolerance, and functional mobility. Patient presents with decreased safety awareness during ADL's. Patient requires increased assistance for ADL participation. The patient would benefit from skilled OT services to target the aforementioned deficits, to assess the need for AE, and increase safe participation with ADLs; increase QOL.
5. Patient verbally consented to visit. Virtual evaluation/ therapy session performed using interactive audio/video technology to reduce risk of patient contracting COVID-19.6
6. Patient verbally consented to telehealth visit. Virtual evaluation performed using interactive audio/video technology w/assistance of (name) to reduce the risk of patient contracting COVID-19.
7. Patient is an 80 y/o male admitted to the SNF for skilled placement following a hospitalization for a fracture of the right femur and surgical repair as a result of a fall. Patient was referred to skilled OT services d/t reduced strength, coordination, increased fall risk resulting in decreased ADL performance and increased caregiver assistance. Patient now requires all assitance w/ADLs.
8. Patient presents w/impairments in balance and motor coordination/strength w/limitations in mobility. D/t the documented physical impairments and associated deficits the patient is at risk for further decline in function.
9. Patient demonstrates significant decline in overall weakness, balance, activity tolerance is also very poor w/inability to perform bed mobility, sit to stand transfers and ambulation. Patient now w/foley catheter removed but refuses to assist w/getting up out of bed for fear of falling which can also increase risk of skin breakdown. Patient is dep A for all bed mobility, transfers, and functional mobility tasks as evidenced by 20 seconds on the 5 time sit to stand test or HIGH fall risk w/anxiety and fear of falling which compromises her safety during all mobility tasks at this time.
10. Pt showed progress at a result of skilled interventions this reporting period. Pt increase FIST of 51/56 noted this reporting period. Pt also demonstrated increase Barthel score of 75/100. Pt is able to transfer from w/c to toilet at I using grab bars for support during toileting task. Pt showed Dynamometer R grip strength of 29.1 kg. Pt required S/U for LB dressing task to following safety precautions secondary to fall risk and impulsive behaviors. Pt demonstrate activity tolerance of 15 minutes before taking rest break during session.
Goals
1. Patient will tolerate AE (appropriate splint to be assessed) x 1 hour with no redness or swelling to manage contracture to LUE.
2. Patient will demonstrate 100% knowledge of sequencing during ADLs as seen through return demonstration and feedback.
3. Patient will increase bilateral R shoulder flexion/extension strength to 4/5 in order to increase safety c ADL/self-care tasks and decrease risk for falls.
4. Patient will increase bilateral R elbow flexion/extension strength to 4/5 in order to increase safety c ADL/self-care tasks and decrease risk for falls.
5. Caregiver/patient will demonstrate 100% knowledge of RNP as seen through return demonstration and feedback.
6. Caregiver/patient will demonstrate 100% knowledge of home assessment recommendations as seen through return demonstration and feedback.
7. Patient will decrease risk for falls as evidenced by an increase in score to 16 inches on Modified Functional Reach Test indicating no risk for falls.
8. Patient will increase RUE PROM elbow extension from 90 degrees elbow flexion to 45 degrees.
9. Patient will increase functional ax tolerance to 1 hour in order to increase participation within environment and QOL.
10. Patient will increase RUE strength to … kg on the dynamometer in order to increase independence with ADL/IADLs.
11. Patient’s modified Barthel Index Score will improve from xx/xxx; xx% impairment/limitation/restriction to xx/xxx; xx% impairment/limitation/restriction.
12. Patient will perform shower chair transfers with … A w/o falls.
13. Patient will perform toilet/commode transfers with … A w/o falls.
14. Patient will decrease risk for falls as evidenced by an increase in score to 56/56 on the FIST Test.
15. Patient will increase dynamic sitting balance to … using righting reactions 100% of the time in order to increase independence with ADL/self-care tasks.
16. Patient will increase dynamic standing balance to Good using righting reactions 100% of the time in order to safely perform toilet/commode transfers with mod I.
17. Patient will demonstrate increased intentional active reach movements with LUE by reaching for objects with TD+ 25% of the time or more in order to initiate participation with environment and BADLs.
18. Patient will safely perform functional activities of choice for 2 hours w/o falls in order to facilitate ability to live in environment w/least amount of supervision and assistance.
19. Patient will increase RUE PROM thumb extension (IP joint) from 90 degrees thumb flexion to 45 degrees.
20. Patient will increase ability to stand supported x 2 hours w/o falls in order to increase participation with ADL tasks.
21. Patient will increase functional mobility during ADLs to mod I in order to increase I c ADL/self-care tasks and QOL.
22. Patient will exhibit a decrease in edema in LUE to slight in order to facilitate patient’s ability to perform ADL/self-care tasks.
23. Patient will identify 3/3 fall prevention strategies with mod verbal cues, via verbal and/or return demonstration with 100% accuracy to reduce the risk of falls.
Baseline: Max A 0/3 Ask for assistance during ambulating, Lock wheelchair, Footwear, obstacles, call light etc
24. Patient will tolerate PROM/manual techniques to BUE 50% or more of the time with min to no pain in order to decrease risk of contractures, increase joint mobility, and preserve skin/joint integrity.
25. Patient will demonstrate adequate self-care skills independently w/in 2 weeks.
26. Patient will identify at least 5 positive effects of proper personal care on her mental and physical health independently.
27. Patient will select clothes and dress up safely w/minimal physical assistance after 5 sessions.
28. Patient will independently perform oral hygiene 5/5 days to maintain proper self-care skills.
29. Patient will be able to communicate w/others adequately w/in 2 weeks.
30. Patient will demonstrate proper eye contact with the therapist while communicating with minimal verbal cues 3/5 attempts.
31. Patient will speak slowly and clearly with other patients while socializing in a group setting using proper tone of voice 3/5 days.
32. Patient will be able to communicate w/others adequately w/in 2 weeks.
33. Patient will complete a 20 minute group activity and follow instructions attentively 2/3 group activities weekly.
34. Patient will develop high self-esteem and express herself positively after 2 weeks.
35. Patient will recognize and mention 5 of their strength and positive potential independently after 5 sessions.
36. Patient will finish a 15 minute cheerful activity and praise self independently w/in 5 sessions.
37. Patient will perform a previously enjoyed interest and develop a new one with minimal visual self-exploration cues after 1 week.
Ther ex
1. OT instructed patient in ther ex to increase strength, coordination, and functional ax tolerance via chest press, lat pull, bicep/tricep curl ex x 12 reps x 3 sets each movement c 12 inch green theraband (100% stretch) and 1lb ther dowel. OT instructed patient in making mind-muscle connection to activate and isolate muscle activation of targeted muscles using proper form and technique, c slow, controlled movement on eccentric portion of movements.
2. Patient directed in NuStep training to increase biofeedback to BUE, mimic reciprocal pattern and increase overall BUE strength to decrease abnormal movement pattern. Patient completed x 15 minutes with OT facilitating interval training of varying resistance 1-2 minutes. Patient required verbal cues for erect posture to maximize cardiopulmonary function. O2 monitored pre, during and post exercise with O2 levels > 95% to ensure positive response and reduce risk of desaturation. Patient denied shortness of breath and indicated just right challenge.
3. Patient arrived at skilled OT complaining of 5/10 R shoulder pain limiting UE dressing tasks. R shoulder ROM measurements taken as follows: OT assessed and measured R shoulder flexion: 60 degrees, ABD: 58 degrees, EXT: 20 degrees, IR: 20 degrees, ER: 25 degrees. Patient instructed in the following exercises to increase RUE ROM, decrease stiffness and reduce pain level: pulleys 1-2 minutes x 3 trials to increase shoulder flexion with short rest in between trials. Patient reported no increase in pain. OT individualized and instructed patient in AROM exercises to max patient range in pain free zone as follows: IR/ER, abd/add 1×10, extension with 3 second hold. Patient reported “it feels looser.” Patient verbalized 3/10 pain post session indicating positive results from directed exercises.
4. Patient instructed in the following exercises to increase L wrist/hand ROM, decrease stiffness, reduce pain in order to utilize L hand in task s/p wrist fx. Patient now cleared to begin ROM exercises per MD documentation. Patient is L hand dominant. Patient instructed in L wrist flex/ext, radial/ulnar deviation, opposition, finger abd/add, MCP flex/ext, PIP flex/ext 2×10 with therapeutic rest as needed. Tactile, verbal and visual cues needed to isolate targeted muscle groups. Patient with difficulty noted for radial/ulnar deviation thus OT stabilized patient at the wrist joint to perform accurately and patient was able to complete with overall less pain.
5. Patient instructed in UE bike to maximize UE ROM and strength for improved overall function in tasks. OT graded the task based on patient’s response to exercise. Patient instructed in 5 minutes of level 1 resistance then graded to level 2 resistance for 5 minutes and finally level 3 resistance for the remainder of task. Patient denied SOB or pain, but reported “that was a good workout.” O2 monitored pre, during, and post exercise with readings > 94%. Verbal cues were provided to improve postural alignment and engage in pursed lipped breathing to maximize functional tolerance. Increased time needed for proper positioning prior to exercise to ensure optimal execution of task.
6. OT developed HEP and patient instructed in self ROM/stretches to increase I with HEP for BUE exercises. Educated on individualized HEP program, reviewed and facilitated exercises with min vc to initiate. OT facilitated patient to complete scap elevation/depression, scap retraction/protraction with 1×10 with 10 second hold. Patient instructed in green TB exercises for chest fly, shoulder abd, shoulder flexion, elbow flex and extension 2×15. OT modified tasks as needed to allow therapeutic rest needed to maximize strength and functional tolerance. Patient will require further training to ensure I, recall, and overall competence with HEP prior to discharge.
7. OT developed functional activity tolerance program and instructed patient in NuStep training to increase biofeedback to BUE, mimic reciprocal pattern and increase overall UE strength to decrease abnormal movement pattern. Overall, patient completed x 15 minutes with OT directing patient with interval training of grading resistance 1-2 minutes. O2 monitored pre, during and post exercise with O2 levels > 95%. OT provided cues to maintain hips in neutral vs. add during task, cues to maintain SPM >55, cues for pursed lipped breathing. RR <20 following task and RPE 2. With OT direction, patient completed task with symmetrical movement 90% of the time.
8. Patient arrived at OT for engagement in incontinence management including PME’s to reduce urinary urgency. Patient reporting 3 episodes of nocturia increasing risks of falls. OT developed program and patient was instructed in variety of exercises to increase pelvic musculature, reduce urgency and bladder control for overall reduced falls. Patient instructed in glute squeeze, Kegels, hip abd, hip add with pelvic floor activation holding 5 seconds each 3×10. Patient required initial visual demo for ability to isolate targeted muscles and increase carry over. After intervention, was then able to carry out with intermittent cues for pacing and staying on task. By end of session, patient stated, “I have noticed I am able to hold it in longer.”
9. Patient arrived at therapy 6 weeks post R humeral fracture. New orders from MD for patient to begin ROM per protocol. Patient educated on purpose and instructed in Codman’s exercise x 1-minute x 5 RUE clockwise, then counter clockwise. OT provided stabilization at the shoulder to ensure proper form and to prevent injury. Max vc to execute properly. Patient required standing rest breaks in between each set and 2 seated rest breaks overall. Patient was limited by pain and fatigue, but with encouragement and stabilization, improvement and tolerance noted.
10. Patient is at risk for increased back pain without training to stabilize core muscles. OT instructed patient in variety of core strengthening exercises to decrease complaints of back pain. In supine, patient positioned properly to train in posterior pelvic tilts, abdominal crunches 2x 15. Verbal and tactile cues provided to isolate targeted muscle groups and reduce substitution methods. OT graded task to perform in standing side crunches with 5# weight x 10 each side with CGA at times for balance. Patient then instructed in 30 second planks x 3 with rest breaks in between planks to maximize tolerance. Progress to minimal 40 second planks next session but encourage patient to complete to point of fatigue.
11. Patient instructed on aerobic/strengthening to increase R and L glute, quad, and hamstring strength and endurance in order to increase transfer, blance to reduce fall risk, patient educated on muscles to facilitate the mind-muscle connection and facilitate increased motor response during treatment. Level 2-constant verbal cues to continue adherence to task.
Ther Ax
1. Patient engaged in ther ax to increase dynamic standing balance and GM/proximal strength via omnistand at level 2 (11 degrees in all planes). Patient's standing tolerance at 10 minutes before needing rest break. OT instructed patient to widen stance to shoulder width for larger BOS (base of support) and to take a step in order to increase righting reaction when patient feels as though he is falling, requiring verbal cues x 50% of time.
2. Patient requires min/CGA for w/c <-> bed transfer. OT instructed patient in proper sequencing via scooting to EOB/wheelchair, leaning forward c nose over knees, and pushing off c UEs and safety precautions when transferring via making sure brakes are locked and using UEs for a controlled movement to guide self when perform stand to sit transfer.
3. Patient required mod A to perform bed <-> w/c transfer c sliding board x 10 sets. OT instructed patient in proper hand placement and activating core, using UEs to transfer via sliding board.
4. Patient engaged in functional mobility c hemi-walker x 50 feet x 2 sets c CGA/min A. OT instructed patient in proper use of hemi-walker c placement on dominant side, using hemi-walker in reciprocity to non-dominant side.
5. Patient engaged in ther ax to increase functional mobility and maneuverability c stairs via 4-step stairs x 5 to simulate stairs at patient's home. Patient completed stair climbing on 4-step x 5 c SBA x 3 sets c rest breaks and pulse, oxygen monitoring via pulse oximeter in between sets. Patient then simulated carrying groceries up stairs via holding 10 lb dumbbell whilst stair climbing on 4-step x 5 c SBA x 3 sets c rest breaks and pulse, oxygen monitoring via pulse oximeter in between sets. OT trained patient in improving safety with gait when negotiating thresholds while following visual cues.
6. Patient c increased AROM to ankle joint to place feet flat on floor in standing position (decrease toe-walking, decrease risk for falls). Patient completed sit <-> stand x 10 reps x 3 sets c rest breaks in between sets c min A. OT instructed patient in proper form while standing to engage in dorsiflexion to neutral bilaterally. OT instructed patient in proper sequencing via scooting to edge of wheelchair, leaning forward c nose over knees, and pushing off c UEs and safety precautions when transferring via making sure brakes are locked and using UEs for a controlled movement to guide self when perform stand to sit transfer. Ther Ex: therapeutic resistance exercises, progressive resistance exercises and therapeutic graded exercises.
7. Patient arrived at OT with R UE weakness s/p CVA. Post estim to facilitate muscle contraction, patient was instructed in the following exercises to facilitate improved voluntary muscle movement. Patient instructed in GE towel slides flexion/extension and horiz add/abd on table top 3×10 with assistance of LUE as needed; however, OT facilitated constraint therapy to increase RUE movement. Patient frustrated at times, but OT provided hand over hand as needed and patient with resultant improved performance.
8. OT facilitated forward reaching activities at 90 degrees of shoulder flexion. Patient was given a 4 lb. on B wrists simulating item retrieval from shelves, placing the item on the floor and returning to the shelf. Patient performed the activity 10 x 1 set with reports of right anterior shoulder discomfort by the 7th attempt. Patient required 25% verbal and tactile cues to perform proper lifting technique following rotator cuff injury. OT graded the task after a 5-minute therapeutic rest break to then retrieve items at a 125 degree of shoulder flexion reaching. Similar discomfort was reported by the 4th trial. Patient educated on various pain relief techniques that patient could perform at home. Patient verbalized understanding.
9. In unsupported seated position, patient was instructed in dynamic reaching tasks to facilitate increased ability and improved balance to independently reach in her kitchen cabinets from w/c level. OT facilitated task to incorporate functional reaching in all planes using BUE to retrieve objects. Patient required min verbal cues and visual demo to initiate, CGA at times needed to maintain sitting balance. Most difficulty noted when reaching above 140 degrees in B shoulder flexion as muscles fatigued easily. OT provided tactile guiding to maximize performance and decrease substitution (lateral trunk flexion) to achieve optimal performance.
10. Patient directed in functional standing task incorporating functional reach outside base of support/all planes to increase ability to reach for items in closet while reducing risk of falls. OT provided pelvic stabilization as well as minimal verbal cues to decrease substitution methods and promote safety awareness. Task graded to incorporate standing tasks on uneven surface. On uneven surface, patient with loss of balance requiring mod A for proper weight shifting, all 4 trials. Will continue to require dynamic standing/reaching interventions to reduce fall risks and maximize balance recovery strategies.
11. Patient instructed in multiple squatting activities in attempt to improve functional mobility and safety, ability to retrieve items from floor level, reduce falls, and improve independence at home. OT facilitated mobility tasks without use of assistive device to retrieve multiple items from floor level. Patient required CGA and mod verbal cues to get closer to object, hold object closer to the body to reduce lumbar strain as well as cues for posture, and technique to facilitate quad contraction. Patient educated on the need to reduce excessive lumbar flexion during task to reduce injury and promote proper lifting techniques.
12. Patient arrived at skilled OT complaining of 4/10 R shoulder pain limiting UE dressing tasks. Upon assessment, patient unable to raise RUE against gravity. Patient instructed in gravity eliminated reaching task on table top to increase R shoulder flexion, extension, horizontal abduction/adduction to improve ability for dressing tasks. OT provided intermittent tactile cues to reduce compensatory strategies and isolate targeted muscle groups needed for functional task. As patient’s pain subsides, progress to against gravity reaching tasks next session.
13. Patient instructed in table top task incorporating L wrist flexion/extension, radial/ulnar deviation, finger flex/extension, opposition movements to increase ROM, decrease stiffness, reduce pain to utilize L hand in functional tasks s/p wrist fx. Patient is L hand dominant. Patient instructed in familiar household tasks (lifting coffee cup, transporting small, light objects from one location to another). Tasks incorporated the need for patient to stabilize wrist against gravity, engage in L wrist flex/ext, radial/ulnar deviation, opposition movements with therapeutic rest as needed. Min tactile, verbal, and visual cues needed to isolate targeted muscle groups. Patient with difficulty noted for radial/ulnar deviation, thus, OT stabilized patient at the wrist joint to perform accurately and patient was able to complete with overall less pain.
14. OT educated patient in B hand manipulation tasks post estim to improve overall grip/pincer grasps needed for ADLs/IADLs. Patient trained in fine motor tasks involving various sized objects (coins, buttons, paper clips) to increase various pinches and functional use. Patient required mod vc and visual demo to perform correctly as patient had difficulty isolating digits. Post functional task: OT assessed and measured R and L lateral and tip pinch lateral: 12# R and 11# L and tip pinch 5# bilaterally (an improvement of 1# each hand for tip pinch from last session). Patient denied pain, just complained of overall stiffness. Patient reported overall functional progress with ability to button and manipulate coins during IADLs since her last session which is helping with dressing and shopping tasks.
15. Patient presents to skilled OT following CHF exacerbation with reports of feeling breathlessness with functional activities. Patient educated on use of functional activity tolerance training techniques to increase overall pulmonary function. O2 and RR levels were closely monitored throughout task with no abnormal response from baseline when patient was assessed (O2 95%-97%, RR 18-22). OT facilitated patient in performing activity tolerance task incorporating 10 minutes of dynamic standing without rest on various surface heights. OT further graded task to engage in overhead reaching in one leg stance. Patient with noted difficulty during this task requiring min A to maintain balance while reaching.
16. Patient presents to skilled OT s/p fall in patient’s bedroom resulting in L sided hip pain and overall weakness. Without OT, patient is at risk for further decline as patient lives alone and was I with all tasks. Due to L sided hip pain, patient having noted difficulty getting off low surface heights of bed. Patient instructed in variety of sit to stands, stands to sits from multiple surface heights to increase overall function. Patient required min A initially and was provided cues for technique including hand, feet, and trunk placement. By the 4th trial, patient was able to complete with supervision. Patient was also provided with pictorial handout providing adaptive equipment (bed risers) recommendations as a resource to heighten the bed to allow for smoother and less difficult transitions from his low bed if this continues to be an issue for him. Will require follow up next session to ensure independence.
17. In standing, with unilateral upper UE support as needed, patient instructed in single stance tasks to facilitate improved standing balance while reaching for overhead items. Patient instructed in single leg raise while reaching for overhead items with initial max vc and tactile cues to illicit appropriate muscles to maintain balance as well as cues to maintain hips in neutral. Progressed patient this session to standing with no UE support; however, did require min A for proper balance recovery techniques when engaging in functional reaching (simulating reaching for grooming items in bathroom). Patient with min cues for posture to reduce trunk sway with standing tasks.
18. Patient arrived at OT with R UE weakness s/p CVA. Post estim to facilitate muscle contraction, patient was instructed in the following to facilitate improved voluntary muscle movement. Patient instructed in manipulation tasks (transporting small objects of paper clip size) incorporating all R hand digits to increase functional use of R hand needed for ADLs with assistance of LUE as needed; however, OT facilitated constraint therapy to increase RUE movement. Patient frustrated at times, but OT provided hand over hand as needed and patient with resultant improved performance.
19. Patient is at risk for increased back pain without training to stabilize core muscles. OT instructed patient in functional mobility tasks while engaging core strength when carrying 10-pound items from one location to another (30 feet apart) using both hands x 3 trials. Patient required mod vc for proper body mechanics during lifting and carrying to reduce further injury and reports of pain. With recommendations, patient completed task without pain. OT graded task to perform using only one hand to carry items another 5 trials. Patient was able to do this with 2/10 back pain. Patient reports overall improvement at home when carrying items of less weight from refrigerator to kitchen table (i.e. gallon of milk) with less reports of pain; however, larger items (needed for yard work) with increased pain. Continue to progress with heavier weight next session and continue to address proper body mechanics and technique.
20. Patient instructed in obstacle negotiation task to reduce falls during in home mobility item retrieval. OT facilitated weight shifting tasks in standing providing tactile guiding when needed (approx. 25% of the time). OT graded the task by incorporating distraction for scanning for items in environment. Patient had one instance of LOB requiring min A, but overall improvement noted. Continue to focus on high level mobility/standing tasks with scanning to reduce falls in the home during functional tasks.
21. Clinician provided minimum assistance while patient performed standing tolerance focused on picking up object on floor and placing on bedside table...
22. OT educated patient in B hand strengthening exercises post estim to improve overall grip/pincer grasps. Patient trained in the following exercises using moderately resistive putty in order to increase gross grasp and various pinches: gross grasp, opposition, abd/add, tip pinch. Patient required vc and visual demo to perform correctly. Post exercise OT assessed and measured gross grasp: 40# L, 42# R, tip pinch 7# bilaterally (an improvement of 2# each hand for gross grasp and 1# improvement bilaterally for tip pinch from last session). Patient denied pain, just complained of overall “weakness.” Patient reported functional progress with opening jars in prep for feeding and grooming tasks.
Self-care
1. OT instructed patient via HOH technique to improve ability to brush teeth. OT assessed patient’s ability to correctly sequence ADL. Patient required constant verbal and tactile cues to perform task.
2. Patient completed toileting task c SBA/supervised A. OT trained patient in utilizing grab bars and FWW to ensure safety when engaging in toileting tasks and to decrease risk for falls.
3. OT instructed patient to position shirt face down on lap. Therapist instructed patient to utilize strong arm and thread weaker arm through the correct sleeve. Min A w/verbal cues provided for patient to lean forward in order for weak arm to swing out and free from torso...
4. OT facilitated muscle synergy of pelvic musculature for smooth moevement control during the stand pivot motion in order to complete wheelchair <-> toilet transfers. Patient required minimal assist and 25% verbal cues for anterior hand placement providing tactile cues to maintain center of gravity and decrease fall risk.
5. Analysis of ADLs for POC. Skilled interventions to facilitate indpendence w/self-feeding abilities included provision of w/c seating during self-feeding.
Neuromuscular re-education
1. OT instructed patient in neuro reeducation techniques to increase dynamic standing balance via crossing midline bilaterally c arms at 90 degree shoulder flexion and full elbow extension in standing x 10 reps x 3 sets bilaterally. Patient demonstrates F-/F dynamic standing balance. OT instructed patient to widen stance to shoulder width for larger BOS (base of support), requiring verbal cues x 50% of time.
2. OT provided moderate tactile and verbal cues to enable patient to perform open-chain shoulder exercises w/closed eyes in order to facilitate proper scapulohumeral rhythm and position sense to increase proper overhead IADL tasks...
3. Clinician provided moderate tactile cues to patient during balance training on foam pad focusing on ankle strategy and somatosensory balance...
E-stim
1. E-stim, neuromuscular re-education protocol applied to LUE pressure points (web space between the thumb and index finger, lateral end of the transverse elbow crease when elbow is flexed, dorsal surface of the shoulder posterior and inferior to the acromion, and midway between the spinous process of c7 and the acromion) at 45 mA x 30 minutes.
2. E-stim, decrease muscle tone-spasm protocol applied to flexor retinaculum, biceps, triceps, and posterior forearm musculature at 20 mA x 30 minutes.
3. E-stim, acute pain protocol applied to LUE anterior deltoid, posterior trapezius, latissimus dorsi, and lateral muscle group of biceps and triceps at 35 mA x 15 minutes.
4. E-stim, chronic pain protocol applied to bilateral splenius capitis muscle and posterior trapezius muscle at 25 mA x 30 minutes.
5. E-stim, acute pain protocol applied to L vastus lateralis, tensor fasciae latae, and biceps femoris insertion points at 105 mA x 30 minutes.
6. E-Stim applied to right shoulder/RUE anterior deltoid, posterior trapezius, latissimus dorsi, and lateral muscle group of biceps and triceps in order to reduce pain, control/manage pain, eliminate pain, increase ROM, increase circulation, facilitate functional skill performance, restore functional skills during daily living tasks, enhance functional mobility and decrease abnormal movement pattern with intensity level, durations and settings at 35 mA x 15 minutes.
7. E-Stim, chronic pain protocol applied to left and right knee; vastus lateralis, vastus medialis, tibialis anterior, and proximal/anterior portion of gastrocnemius muscle for purpose(s) of decreasing pain and intensity level/settings at 20 mA x 15 minutes each.
Diathermy
1. Diathermy applied to right shoulder for 15 minutes for purposes of reduce chronic pain, facilitate functional skill performance, enhance functional skills during daily living tasks, facilitate functional mobility, increase range of motion and facilitate circulation with intensity level/settings at 4 delta T.
US
Manual Therapy
1. PROM applied to cervical spine via lateral extension static stretch x 15 minutes from 60 degrees lateral flexion to 45 degrees lateral flexion. Manual Tx: joint mobilization techniques, stretching of shortened connective tissue, manipulation techniques, myofascial release and manual traction.
2. PROM and manual tx applied to RUE utilizing proximal to distal massage in order to decrease edema.
3. PROM applied to bilateral LEs in order to facilitate proper standing position to decrease risk for falls via static stretch to posterior muscles of bilateral LEs x 15 minutes. Manual Tx: joint mobilization tecnhniques, stretching of shortened connective tissue, manipulation techniques, myofascial release and manual traction.
4. Static stretch applied x 1 minute x set to each muscle group via thoracic extension stretch, lumbar extension and abdominal stretch, lumbar flexion/rotation stretch, hamstring stretch, adductor stretch, gluteal stretch, gluteal and lumbar rotation stretch, quadriceps stretch, hip flexor stretch, tensor fascia stretch, and gastrocnemius stretch in order to increase mobility, decrease pain, and increase level of function with participation in ADL/self-care tasks. Manual Tx: joint mobilization techniques, manipulation techniques, manual traction, myofascial release and stretching of shortened connective tissue.
5. Clinician provided passive stretches to B glenohumeral joint sagittal, frontal, and horizontal plane, elbows in sagittal plane and wrist in sagittal and frontal planes with prolong stretch at end range to decrease risk of contractures and increase ROM. Clinician provided passive stretches to B elbows to increase ROM and facilitate participation with daily activities.
6. Clinician provided passive stretches to R glenohumeral joint sagittal, frontal, and horizontal plane, elbows in sagittal plane and wrist in sagittal and frontal planes with prolong stretch at end range with joint compression to decrease risk of contractures, normalize tone and increase ROM.
7. Clinician provided passive stretches to B shoulder in all planes with prolong stretch at end range to decrease risk of contractures and increase ROM in order to facilitate participation with daily activities. Pt required HOH to complete task this date.
8. Clinician provided passive stretches to B shoulder in all planes, elbows and wrist with prolong stretch at end range to decrease risk of contractures and increase ROM.
9. Clinician provided joint mobilization of B MCP, DIP, PIP, and wrist to normalize tone and increase ROM in order to tolerate B hand carrot splint and assist with self-care task. Pt tolerance session with no signs of pain or discomfort.
10. Clinician provided patellar mobilizations to improve knee extension and flexion motions, reduced ROM limitation in order to improve functional transfers...
Physical Therapy/Ambulation Notes
1. OT instructed patient in increasing hip flexion during swing phase of gait in order to improve foot clearance when negotiating thresholds or uneven surfaces, requiring verbal cues 50% of time.
2. OT trained patient in improving safety with gait when negotiating thresholds while following visual cues.
3. Clinician instructed patient to focus on short vs. long stride length, reduced velocity while ambulating on uneven surfaces in outdoor courtyard to reduce fall risk...