Occupation in Adult Neuro Rehab

Division of Occupational Therapy

University of Utah
WEEKLY PROGRESS NOTE:

S:
Client expressed fatigue via nonverbal communication in the last 15 minutes of tx
session.
O&A:
Client presented with posterior pelvic tilt and flexion of thoracic spine while
seated on a mat. Stretching and mobilization of the pelvis and thoracic spine was
performed to facilitate anterior pelvic tilt and thoracic spine extension. After
receiving facilitation, client maintained upright posture while seated for 1 minute
and completed eccentric and concentric contractions for these movements.
Clients was dependent on therapist to open hand and position in WBing
position on paddle 2* to high tone. Client completed moving body and stable arm
movements to stretch the hand, wrist and forearm muscles. Client was
dependant to maintain RUE in WBing position 2* decreased activation of right
side muscles. Client completed seated reaching task with less affected LUE
towards the right more affected side with assistance from OT to extend elbow
and bear weight through right upper and lower extremities.
Clients more affected RUE was positioned so that elbow extension could
be completed in a gravity-assisted position. Client was dependent on OT to
extend elbow concentrically 2* to weakness; however, client was able to maintain
elbow in extended position isometrically for 5 seconds with 2-3 verbal cues from
therapist. Client was also able to complete eccentric contraction while bringing
elbow from extension into flexion. Active extension via isometric and eccentric
contractions indicates minimal muscle activation at the elbow joint (Triceps mm).
This is an improvement from the previous session in which client was dependant
on therapist to straighten elbow in WBing position during reaching tasks.
Client received education on body mechanics during sit to stand transfers
with quad cane. After therapist positioned RUE under clients BOS, client was
able to complete transfer with Min A but placed more weight through less
affected LLE than more affected RLE. Client was able to complete stand to sit
transfers with 2 verbal cues to reach back to mat while sitting down.
P:
Activity
1.Stretching mobilization
at pelvis, thoracic spine,
AND (new this week)
scapula/humerus.
-Cervical spine extension

Set up/Equipment
Mat

Rationale
Client is doing well with
pelvic/thoracic spine
movement and is able to
complete concentric
contraction.

and scapular retraction

-Scapular depression
-External rotation of
humerus
-Shoulder flexion
2. WBing/reaching task
towards affected sidevary distances and
surface heights for
reaching as clients RUE
muscles are stretched.

Cards or clips or other

reaching items
Table
Mat
R hand paddle
Dycem

A standing task
addresses clients
decreased balance and
endurance.

Depending on clients
fatigue level, I may ask
her to complete this
reaching task (while
WBing through RUE) in
a standing position to
grade up (and to address
balance and equal
WBing through both LE)
3. Gravity assisted elbow
extension via chair or
pipe frame

R hand paddle
Chair
Dycem
Phone books

4. Gravity minimized
horizontal
abduction/adduction

Table
Pillow case

I might complete
scapular/humeral
stretching and
mobilization prior to this
activity instead of at the
beginning of the session
5.

These additional
stretches are a step up
and appropriate for the
client because of high
tone in surrounding
scapular mm.
Client has very little
activation in RUE and
needs continued WBing
through more affected
side to facilitate this.

Client demonstrated
some muscle activation
at elbow, as she was
able to complete
isometric and eccentric
contractions. This activity
will continue to facilitate
increased strength in
RUE.
This is a step up from
activity #3. The client
wanted to be able to
incorporate her RUE into
functional tasks- this
activity is preparatory for
table top cleaning
activities.

**Chris- A lot of my activities are very similar from week to week- I am trying to
give some variation (different reaching tasks), but I feel really repetitive because

my clients abilities are very low level so she needs a lot of WBing, stretching
etc. Is this acceptable? Can you think of any creative ways to address what she
needs without being as redundant? Please let me know. Thanks- Ashley
STGs:
Same as last week
If more than two weeks old, explanation as to why no changes needed:
___________________________________________________________
Revised
If modified to decrease the level of difficulty/challenge, explanation as to
why this was done: _After new info was presented in class, this goal was
not realistic for the STG time frame and other activities needed to be
completed prior to this. So, I used the same goal but just adjusted the
timeframe.
STG 1. Within three weeks (of initial eval), client will complete sit to stand
transfer with no verbal or tactile cues to maintain anteriorly rotated pelvis while
leaning forward.

Original STG 2. Within two weeks, client will achieve 50* active horizontal
ab/adduction in a gravity minimized position in order to participate in simple
cleaning tasks.
New STG 2: Within 5 weeks, client will achieve 50* active horizontal
ab/adduction in a gravity minimized position in order to participate in simple
cleaning tasks.

STG 3. Within 3 weeks (of initial eval) client will complete seated functional reach
task with left less affected hand while weight bearing through more affected RUE
with min A to stabilize RUE in place on mat.

Revisions to LTGs if needed:

LTGs are all the same.

___Ashley Moore_____________________________
Occupational Therapy Student Signature

_10/31/14_