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Occupation in Adult Neuro Rehab

Division of Occupational Therapy


University of Utah
WEEKLY PROGRESS NOTE:
Date: 10-29-14
S: It just seems kind of awkward. My whole right arm is just awkward to use.
O: Client participated in 90 minutes of outpatient occupational therapy in the
occupational therapy clinic. Client presented with internally rotated humerus and
flexor synergy in the elbow, wrist and digits in resting position. Client participated
in right UE weight-bearing activity for ten minutes in preparation for functional
activity. Following weight bearing client participated in AROM and PROM of the
shoulder, elbow, wrist and digits. After the completion of weight bearing and
stretching the client gained 20 degrees of elbow extension to achieve 40 degrees
of flexion.
Client participated in stable arm on moving body using the pipe frame for 2
sets of ten repetitions requiring verbal and tactile cueing for upright sitting. Client
performed 2 sets of 10 reps of stable body moving arm using his R UE and the
pipe frame. He required tapping of the tricep and verbal cueing to extend to 20
degrees of extension which is his current available range. Client required only
verbal cueing after 15 repetitions. Client completed 2 sets of 10 repetitions of
elbow extension with his RUE using a chair instead of a pipe frame with verbal
and tactile cueing for elbow extension.
Client completed 2 sets of 15 repetitions of R shoulder flexion by rolling a
tennis ball up the wall in standing. Client required moderate tactile and verbal
cueing to prevent compensatory hiking of the shoulder for the first twenty
repetitions. For the remaining repetitions, client required only min tactile and
verbal cueing for shoulder positioning during shoulder flexion. Client completed 3
sets of 10 R active-assisted supination exercises using a hammer. During the
activity client was able to achieve full range of supination with the weight of the
hammer and min assist from the therapist. Verbal cueing was provided to prevent
compensation at the shoulder and elbow. Prior to the activity clients AROM for
supination was 30 degrees. After the activity AROM of supination was 45
degrees. Client was unable to release the hammer at the end of repetitions and
used his left hand to remove the hammer from this right hand. He also used his L
hand to place the hammer into his R hand. Client completed 2 sets of 15
repetitions of R radial and ulnar deviation using a hammer for resistance,
requiring min verbal cueing for UE positioning.
A: Client presents with R UE muscle weakness, and flexor tone of the elbow,
wrist and digits 3-5 secondary to R CVA. Client has made progress towards
goals as seen through requiring less assist to perform elbow extension in
available range. This shows progress towards LTG 1. At the beginning of the

session client required moderate verbal and tactile cueing to complete shoulder
flexion without compensation and improved to requiring only min assist which
shows progress towards LTG 2 of UE positioning. Client demonstrated
improvements with AROM of supination since the evaluation which is important in
achieving LTG 3. Client continues to demonstrate decreased strength of the R
UE and utilize compensatory movements. He will benefit from continued
occupational therapy for motor rehabilitation.
P: For next week. Describe all activities you plan to do.
Activity
1. Begin session with
preparatory work
including 10 minutes
of R UE weight
bearing while sitting
on the mat., AROM
and PROM of
shoulder external
roation, flexion and
extension, elbow
extension, wrist
extension,
supination,
pronation, ulnar and
radial deviation
2. Tennis ball on the
wall activity to focus
on shoulder flexion
without
compensation.

Set up/Equipment
Therapist and mat table

Rationale
Clients flexor tone
significantly decreases
with weight bearing.
Client requires stretching
prior to functional activity.

Tennis ball
wall

3. Cooking activity:
dipping pretzels.

Pretzels
Melting chocolate
Wax paper
Baking sheet
Bowel
Spoon
Sprinkles

Client participated in this


activity last session and
became more successful
as we progressed. I
would like to see more
progress with shoulder
flexion without shoulder
compensation and
requiring fewer tactile
and verbal cues.
Repetitive reaching task
involving an activity the
client finds meaningful.
Engages UE shoulder,
elbow, wrist and FM. If
too difficult can be graded
down to have the client
dipp pretzel with the left
hand and uses the right
UE to apply the sprinkles.

Client will grab pretzel


using R hand dip it in
melted chocolate and
place it on the tray. This
will engage shoulder and
elbow ROM and strength.
-facilitation will be used

PRN
4.Dishwashing activity:
Dishes and sink
focus on UE positioning
(dishes from cooking
starting proximal to distal, activity)
facilitation to prevent
compensation and
enhance normal
movement. Using R
hand to wash and L hand
as functional assist as
appropriate
5. Supination activity
using dominos. Having
the client use supination
to flip dominos while arm
is rested on the table to
prevent shoulder
compensation

Dominos, table

-can turn into a game of


dominos if appropriate to
include fine motor and
reaching.

Rationale: one of the


clients goals involved
dishwashing so he will be
motivated to participate in
the activity. The activity
utilizes UE positioning,
normal movement and
shoulder and elbow
strengthening. Task will
be graded as needed and
facilitation will be
provided.
Client continues to
present with decreased
strength and ROM with
supination. He is
currently unable to grasp
playing cards and so
something that is thicker
(domino) may be easier
to manipulate.
-grade down place
domino into R hand with
left hand and then
supinate.
-grade up: having him
perform supination
without his forearm
supported

Current long term goals


In 10 weeks, client, will independently prepare simple stove top meal using B UE
and demonstrating full R elbow and wrist AROM.
In 10 weeks, client will independently complete dishwashing with proper B UE
positioning.
In 10 weeks, client will possess adequate R hand fine motor to place dress shirt
on hanger independently without compensatory strategies.
STGs:
X Same as last week
If more than two weeks old, explanation as to why no changes needed:

Client can continue to progress towards goals. They will be revised as


able.
Revised
If modified to decrease the level of difficulty/challenge, explanation as to
why this was done: ___________________________________________
___________________________________________________________
STG 1. In two weeks, client will improve elbow AROM from 45 degrees to 20
degrees of flexion in preparation for stove top cooking.
STG 2. In 2 weeks, client will demonstrate improved humerus rotation to neutral
resting position in preparation for dishwashing.
STG 3. In 2 weeks, client will possess adequate R fine motor ROM and strength
to use finger tip to finger tip grasp to pick up items with min assist for positioning.
Revisions to LTGs if needed:
Melissa Weddington

10-31-14

Occupational Therapy Student Signature

Date

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