Ot balance grading
12. Patient arrived at PT with 4/10 R hip pain. Patient educated and instructed in R hip exercises to increase R hip ROM/strength for improved balance, pain reduction, as well as core strengthening to reduce compensatory strategies for improved posture. In side lying, patient instructed in 3×10 R hip abduction using 2.5# weights, prone L hip extension, supine single leg raise to patient's max tolerance. Able to complete 15 of each exercise prior to modifying task secondary to fatigue. Pt instructed in posterior pelvic tilts 3×10 with 3 sec hold. PT graded task to standing single leg stands for hip flexion and abd on compliant surface 3×10. Patient completed standing Achilles stretch 3x 30sec with mod verbal cues for technique and to engage in pain free range. Min A provided due to RE weakness and prevention of substitution movements. PT assessed progress as follows: Increase of 4 degrees R hip flexion, 3 degrees hip abduction and 2 degrees in extension post ther ex when compared to previous session. Patient was able to execute with no increase in pain in prep for gait training. 11. 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. 6. PT 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. 13. PT developed functional activity tolerance program and instructed patient in NuStep training to increase biofeedback to BLE, mimic reciprocal pattern and increase overall LE strength to decrease abnormal gait pattern. Overall, patient completed x 15 minutes with PT directing patient with interval training of grading resistance 1-2 minutes. O2 monitored pre, during and post exercise with O2 levels > 95%. PT provided cues to maintain hips in neutral vs. add during task, cues to maintain SPM >55, cues for pursed lipped breathing. RR. To help therapists and assistants improve their documentation, the following are examples of documentation that clearly demonstrates the skilled nature of therapeutic exercise. (Skilled terminology is highlighted in red.). 3. Patient directed in NuStep training to increase biofeedback to BLE, mimic reciprocal pattern and increase overall BLE strength to decrease abnormal gait pattern. Patient completed x 15 minutes with PT 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. Care is regarded as "skilled" only if it is at a level of complexity and sophistication that requires the services of a therapist or an assistant supervised by a therapist. Services that do not require the performance or supervision of a therapist are not considered "skilled" even if they are performed by a therapist. Auditors often rely on repetitive or otherwise poor documentation to deny a claim based on the conclusion that therapeutic exercise did not require the skills of a therapist. 1. Patient arrived at therapy with 3/10 L hip pain. Patient instructed in L hip exercises to increase L hip ROM/strength for improved balance and overall pain reduction. In side lying, patient instructed in 3×10 L hip abduction, L hip extension with verbal cues to isolate targeted muscle groups and initiate appropriate exercise. Min A provided due to LE weakness and prevention of substitution movements. Increase of 5 degrees in L hip abduction was achieved through exercises since last reporting period. Patient was able to execute with no reported increase in pain in prep for gait training. 7. 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. 4. Patient instructed in BLE recumbent bike training to increase overall functional activity tolerance and LE strength to maximize balance and reduction of falls during mobility. PT directed patient x 18 minutes requiring 2 therapeutic rest breaks due to complaints of fatigue and increased respiration. PT utilized Modified Borg Scale and patient reported 2/10 during exercise. O2 > 96% when monitored during rest breaks, RR 22 post exercise, 18 at baseline. Patient also instructed in pursed lipped breathing to reduce complaints of shortness of breath and elicit usage of energy conservation techniques. Able to mimic after visual demo with good execution. 2. In seated position, patient was instructed in LLE strengthening exercises to decrease left foot drop during ambulation prior to functional mobility task. Patient required min verbal cues and visual demo to initiate each exercise using 2# ankle weights for B knee flex/ext. Using red TB, pt. trained in ankle dorsiflexion, plantar flexion, inversion/eversion with 3 second hold. Required max verbal cues, tactile cues and visual demo to reduce compensatory strategies. PT facilitated patient to complete standing ther ex including heel raises with BUE support, using mirror for visual feedback to ensure proper form, 2×15. Increased time needed to execute and allow for therapeutic rest. Patient reporting exercises are helping him "not drag my foot as often.". The two most important PT/OT documentation requirements are demonstrating that care is (1) medically necessary and (2) skilled. 8. 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. 10. Patient presents to skilled PT s/p fall in patient's bathroom resulting in R sided hip pain and overall weakness. Without PT, patient is at risk for further decline as patient lives alone and was I with all tasks. Due to R sided hip pain, patient having noted difficulty getting out of bed. In supine, patient instructed in R hip abd/add, flex/ext, bridging 3×10 with tactile guiding due to weakness. Increased time needed due to R hip pain as well as to ensure proper form to prevent injury. Will require further skilled services to increase weakened RLE. 9. Patient presents to skilled PT following CHF exacerbation with reports of feeling breathlessness with community ambulation. Patient educated on use of functional activity tolerance training techniques to increase overall pulmonary function. O2 and RR levels were closely monitored throughout exercise with no abnormal response from baseline when patient was assessed. PT facilitated patient in performing activity tolerance task incorporating UE and LE x 5 minutes x 2 trials with rest in between trials. Patient stated, "wow I'm really out of shape," but with education on energy conservation techniques, was able to complete the task. 5. 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. A therapist's skills may be documented by descriptions of skilled treatment, changes made to treatment due to an assessment of the patient's needs on a particular treatment day or changes due to progress the therapist judged sufficient to modify treatment toward the next more complex or difficult task. [ASKDEEIPSNPPET-21-23] May see pronated feet, "winging" in the scapula, hypermobile finger joints, hyper-extended knees, and/or lordosis in lumbar spine. 1. Hold a large dowel with both hands, use this to push a ball back and forth. Play games such as Connect Four in high sidelying. Prone for fine motor activities & games- The elbows provide a point of stability for freeing the hands for manipulating. 4. Use whistles or play games that require blowing through a straw. May see poor trunk extension with accompanying shoulder elevation to compensate for reduced strength. The rib cage may be high in the chest and flared. The TEEN may not spontaneously rotate his/her torso while moving to perform functional tasks; instead will over rely on symmetrical flexion/extension patterns. This will compromise efficient movement for performing functional tasks and result in tightening in certain muscles such as the latissimus and pectorals. Donkey Kicks- raise one leg into extension, then flex/extend knee so as to kick. Superman/Super Woman- prone extension with arms and legs fully extended activates muscles antagonistic to the tonic labyrinthine prone reflex. May appear "disruptive" when required to walk in a line at school. Response: With neck flexion the upper extremities will flex and the lower extremities will extend. With neck extension the upper extremities will extend and the lower extremities will flex. The Sidelying Position offers the opportunity to increase strength and edurance while moving in 3 planes. The TEEN will learn to balance by keeping their head and body oriented in midline; remember to not only focus on maintaining this static position, but transition into and out of sidelying. The TEEN should remain static for brief periods; even minimal weight shifting from the TEEN's center of gravity may activate head and torso righting. Be sure to encourage the use of this posiiton on their right and left sides. This will lengthen muscles needed for full rotation of the trunk. Remember full expression of equilibrium reactions require torso rotation and freedom of movement in the upper and lower extremities. Stimulus: Flexion and extension of the head (neck). Running- Poor reciprocal arm swing; arm fencing posture may present because running requires extra strength and endurance. Overall speed and accuracy will be reduced. May not keep up with peers during movement games and physical education. Impaired Pre-writing & Writing- Writing requires isolated and precise movement of individual body parts; the continued presence of the ATNR interferes with this. When the TEEN rotates his head away from midline, one arm will be influenced to extend and the other to flex. This will impair the stabilization of the paper with non-dominant hand and controlled use of writing tools with the dominant hand. The TEEN may compensate with an immature pencil grasp and need frequent reminders from their teacher to hold his paper. Copying from one source (ex: the board) to another (ex: paper on their desk) requires dissociation of the eyes from the head; the continued presence of the ATNR will also affect this. Keyboard Use - Will impair ability to keep both hands properly positioned at midline on the home row keys; may need to persist with hunt and peck method. Influence of Retained Asymmetrical Tonic Neck Reflex (ATNR):. Importance for Baby: The STNR assists in the development of bilateral patterns of body movement. Allows TEEN to move up against gravity and assume quadruped (on all four's like a dog). Integrates as TEEN begins to crawl and can lift the buttocks from the heels without flexing the neck. Integrated when rocking back and forth on hands and knees. Poor Isolation of Individual Body Movements- Ongoing influence by the ATNR may have affected the TEEN's earlier success with creeping or crawling. The skill of crawling has a developmental sequence of its own. In the beginning the baby simply uses his arms to push himself backward. Ultimately the baby should use quick alternating movements of their arms/legs while only two of four limbs are touching the surface; indicative of intact balance, strength, and ability to isolate movement. TEENren with poor isolation of individual body parts may also show poor grading and accuracy when moving. TEEN uses their own hands to place/remove rings from their feet. Bounce ball off hands while TEEN's shoulders flexed to 90 degrees with elbows straight; therapist drops ball from above for TEEN to volley back. The Primitive Tonic Reflexes appear in infancy and are integrated into normal movement patterns as the infant develops during the first 6-12 months of life. These reflexes are thought to help the infant learn to organize motor behavior. Integration refers to the inhibition by higher centers of neurological control which modify the reflex in such a way that the pattern of response is no longer stereotypical. The reflex does not disappear; it may reactivate under stress or during activities requiring great strength. If these so called primitive reflexes are persistently displayed beyond the expected or typical developmental time period, their presence has been considered an indication that underlying developmental or neurological issues may exist. When these reflexes do not integrate, they may interfere with a TEEN's development of more advanced motor skills. If such a delay or disruption in motor skills exists, there may be an impairment in the TEEN's occupational performance. That is where an Occupational Therapist's skillful assessment and intervention will make the difference for the TEEN! Treatment Considerations: The biomechanical consequence of joint laxity and hypermobility is a poor ability to generate sufficient force for movement. Just as babies develop, when treating be sure to encourage movement in small ranges to develop stability.