INTERVENTION PLAN FOR COMMUNITY CLIENT
Copy/paste one LTG and the matching STG from your evaluation SOAP note. This will be the goal set around which you design your treatment session.
LTG 1: By discharge, the client will independently don socks, shoes, and AFO brace while incorporating his LUE
using compensatory strategies.
STG 1: In 2 weeks, the client will be able to don L shoe over heel while incorporating his LUE using compensatory
strategies with min A.
OCCUPATIONAL
PERFORMANCE PROBLEM
Specifically identify only the client
factors and/or performance skills
that are barriers to the
achievement of this goal. This
should not be a bullet list, rather
you should describe how the client
factor impacts this client’s
performance of the occupation in
the goal.
Client factors:
The client factors impacting the
client’s ability to independently don
his L shoe and sock are minimal
proprioception in his hand, absent
touch functions (light touch), lack
of control of voluntary movement in
his fine motor skills and muscle
tone (high tone) resulting from the
hemiparesis effects of his R
thalamic hemorrhage.
Performance Skills:
The performance skills currently
impacting the client’s performance
with the goal of donning his L sock
OPM and CPM
AND RATIONALE
Identify your OPM and all relevant
CPM’s that best addresses the
performance problem and describe
how each will be used to design
treatment for this client’s specific
problems.
OPM: PEO
The PEO Model will enable me to
create the most optimal solutions
for the client as I take each factor
(support and barrier) into
consideration to effectively modify
the task and environment as
needed to fit the client’s needs and
promote greater occupational
performance and participation.
Person: The client is a 69 y/o male
with a R thalamic hemorrhage
resulting in L hemiparesis, high
tone, extensor synergy, and soft
tissue shortening.
TREATMENT SESSION DESCRIPTION
Provide details of how you will set up the
activity and how your intervention
addresses the performance problem.
Your description should detail how the
activity will be set up to make it
therapeutic.
Activity Set Up
Brief Therapy Outline:
*Set up: Client-centered music is playing
in the background to aid in multisensory
experience for the brain to increase
motor control.
1. Mirror Therapy (MT) ~ 25-30 min
a. Why we are doing MT
b. Before video
c. Preparatory UE exercises
d. Functional tasks
e. Education throughout
exercises
f. After video
2. Typing
a. Typing test
b. Positioning
GRADING THE ACTIVITY
Choose one client factor or
performance skill that you
address in your treatment
session. Describe one way
(only one) that you can grade
the activity up and one way
(only one) to grade the activity
down based on that one factor
or skill.
Factor/Skill: Control of
voluntary movement
Grade Up: Client moves his
LUE on and off the keyboard
every time he uses the a key
and does rest hand on
keyboard.
Grade Down: Client is
supported and positioned with a
rolled towel to lift LUE high
enough above keyboard but still
within reach.
and shoe are positions, reaches,
grip, manipulates and coordinates.
Because of his L sided
hemiparesis, high tone, and overall
weakness he has difficulty
reaching down far enough with his
LUE and the lack of motor control,
create an inability to effectively grip
his sock/shoe to pull them on and
manipulate laces to tie them. He
also has difficulty positioning his
LUE because of a lack of
proprioception and light touch, he
cannot feel when his left hand is
touching the lacks to use his pincer
grip. Also, he has difficulty
coordinating his LUE along with his
right to pull on sock/shoe and tie
laces making task more difficult
and time consuming.
Environment: The environment is c.Occupation-based typing
dressing in his home in preparation project
for work and donning his shoes 3. Homework
back after showering to be able to a. Handouts for home-based
exit safely. MT program
Occupation: Donning his L Supplies:
sock/shoe Mirror Therapy (MT) Supplies:
- 1-Paddle
- Tape
- 4-Wash cloths
CPM: Motor Control/Learning - 15-Washers
Model - 15-Clothes pins
- 1-Pen & paper
The Motor Control/Learning Model - 2-Glass of water
is important to implement b/c of the - 2-Scissors
client’s R thalamic hemorrhage - 2-Sandpaper
resulting in L hemiparesis. His - 2-Bristle brushes
stroke caused a disruption in the - 2-Hard sponge
cortical connection between his
brain and motor movement of his L Typing Supplies:
side. The focus of treatment will be - Desktop keyboard
to promote more repetitious motor - 1-Rolled towel
movements from the LUE to rebuild - 1-Pillow
motor pathways associated with - 2-Rubber bands
donning his socks/shoes. While the - Online typing test to measure
top-priority will the functional wpm and accuracy %.
activities of donning sock/shoe,
other parts of therapy will consist of Multisensory supplies – client centered
adding functional supplementary only
exercises using Mirror Therapy to - Music
target LLE (as per client request). - Speaker
- Chocolate, hard candy
- Grapes
- Nuts
.
Part 1: 25-30 minutes
Mirror Therapy (MT)
Therapist will explain the purpose and
reasoning behind MT. Client should
remove all jewelry and ensure the R UE
appears in the mirror as the L UE.
Therapist will verbally explain and
demonstrate how to position the affected
limb into the mirror box and position the
mirror midline to the client and ensure he
can see the reflection of his RUE in the
mirror. Therapist will also demonstrate
and explain each task with client while
provided needed physical support and
verbal cues to enhance performance.
Therapist will explain that every
movement must be performed slowly,
with both R & L hand, looking only in the
mirror and visualizing the mirror. Each
exercise/task will be completed up to 15
times.

Measurement: Therapist will take a

before and after video of the client
performing preparatory and functional
tasks with his affected L UE to compare
to his performance after completing MT
for 25-30 minutes.

Homework: Client will also be given a

Mirror box to take home and use daily for
10-30 min a day, a handout of exercises,
and a tracking sheet.

Prepatory tasks
- Finger mass flexion/extension
- Wrist supination
- Wrist flexion
- Finger touch
- Circumduction

Functional motor tasks

- Lifting glass of water
- Washing his face
- Brushing hair
- Scissors
- Writing
- Cards
- Pick up Washers
 - Clothespins
- Picking up and eating foods

Sensory Retraining:
- Cold rocks
- Warm washcloth
- Sandpaper
- Hard sponge
- Bristle brushes

Multisensory Approach
- Music therapy (client’s choice)
- Taste: candy, chocolate, salted
nuts, fresh fruits

Part 2: 25-30 minutes

Typing – Occupation Based
Client will first participate in an online
typing test that will measure his wpm
and typing accuracy % which will be
recorded and compared to future typing
tests to measure improvement over time.

Therapist will demonstrate LUE

positioning for LUE to decrease errors
and improve performance. Client’s LUE
will be positioned using a rolled towel
underneath his wrist/hand to raise the
limb so the weight of his hand is not
pressing down on the keys. A pillow can
also be used to support the forearm and
elbow if needed.

Client will type while L UE is supported

and positioned with towel. Client will be
instructed to implement his LUE to type
other nearby keys as much as possible
to further LUE repetitions.

How it will be therapeutic:

Because part of Client’s stroke occurred
in Thalamus--the portion of the brain that
regulates motor control, consciousness,
sleep/wake cycle, sight, sound, taste,
and touch. This therapy session is
designed to take a multisensory
approach to address this portion of the
brain as much as possible. Motor control
and sensory retraining will be heavily
addressed with Mirror Therapy (MT).
Music that the client requests will be
played to increase client motivation and
because music has been shown to be
beneficial to stroke patients in increasing
UE motor function. The multisensory re-
learning tasks will also include
implementing taste during functional
motor tasks and sensory retraining
activities in MT.

Occupation-based: The main goal is to

address Client’s ability to improve his
ability to type increasing his work life
satisfaction and performance.
Environmental changes will be
implemented to support his LUE using a
towel and/or pillow to raise his L
hand/LUE, to prevent him pressing down
on the shift key by accident. Raising his
L hand up will improve his typing
efficiency.

Evidence-Based Research & Client

Education
Provide Client with a foundational
understand of why mirror therapy,
sensory retraining, and a multisensory
approach using music is therapeutic in
retraining his motor and sensory system.

Mirror Therapy
The existing evidence supports the
positive effects of mirror therapy in
stroke patients on the following domains:
• Improving motor function and ADLs
• Reducing pain
• Reducing neglect
• Reducing sensory impairment

Sensorimotor MT shows small

improvements in light touch threshold
and proprioception that appear to be
functionally important for people with
chronic Hemiparesis.

Sensory Retraining
Confirmed effectiveness of sensory re-
learning in combination with task-specific
training on UL functioning after stroke

The sensory and motor systems are

closely related [16], and both systems
are necessary for accurate and precise
movements. To improve overall
functioning of the UL after stroke, it may
therefore be important to focus not solely
on motor training but also on sensory
training. Examples of sensory retraining
include:

(1) touch detection to explore different

surfaces; (2) touch dis- crimination to
identify different materials, shapes,
textures, weights, and temperatures; and
(3) tactile object recognition to examine
and identify different objects and
proprioception

(1) tying shoelaces, doing buttons, and

pulling up a zipper; (2) fine motor training
and bimanual tasks such as pouring
water into a bottle and using cutlery; and
(3) shuffling, dealing, and turning cards
and playing board games.

Multisensory Approach
Music therapy has been shown to help
improve motor where there is stroke-
induced motor dysfunction. Music
therapy may aid in the structural and
functional neural reorganization in the
brain following injury. This is because
there is a strong connection between
music and movement. Playing music can
engage the part of the brain responsible
for movement. Music is also a
predictable stimulus, and the steady beat
can help build coordination.

Record & report forms:

Client will be provided with a weekly
record keeping system to report his daily
progress for his MT home-based
program designed to increase his motor
repetitions and implement sensory
retraining.

How it addresses the

performance problem:

Client will engage in functional motor

tasks, sensory retraining tasks--using a
multisensory approach to improve
overall LUE motor and sensory function
by engaging in repetitive preparatory and
functional tasks using mirror therapy and
through meaningful occupational
performance in typing. The environment
will also be addressed by adding in
compensatory methods of a rolled towel
under the wrist and pillow if needed to
support and position the LUE.

Evidence-Based Research & Client

Education
Provide Client with a foundational
understand of why mirror therapy,
sensory retraining, and a multisensory
approach are therapeutic in helping him
regain as much motor and sensory
function in his LUE as possible.

Mirror Therapy
Sensorimotor MT shows small
improvements in light touch threshold
and proprioception that appear to be
functionally important for people with
chronic hemiparesis. The existing
evidence supports the positive effects of
mirror therapy in stroke patients on the
following domains:
• Improving motor function and ADLs
• Reducing pain
• Reducing neglect
• Reducing sensory impairment

Sensory Retraining
Sensory relearning in combination with
task-specific training is effective on UL
functioning after stroke. Because the
sensory and motor systems are closely
related, both systems are necessary for
accurate and precise movements. To
improve overall functioning of the UL
after stroke, it may therefore be
important to focus not solely on motor
training but also on sensory training.
Examples include: (1) touch detection to
explore different surfaces; (2) touch
discrimination to identify different
materials, shapes, textures, weights, and
temperatures; and (3) tactile object
recognition to examine and identify
different objects and proprioception.
Functional tasks include (1) tying
shoelaces, doing buttons, and pulling up
a zipper; (2) fine motor training and
bimanual tasks such as pouring water
into a bottle and using cutlery; and (3)
shuffling, dealing, and turning cards and
playing board games.

Multisensory Approach
Music is shown to have a positive effect
on treatment of stroke-induced motor
dysfunction. Possible explanations
include, structural and functional neural
reorganization in the brain following
injury. The discovery of the clinical
effectiveness of rhythmic motor
entertainment also brought into focus
that the structural elements of music
have enormous potential in clinical
applications to retrain the injured brain.

Record & report forms:

Client will be provided with a weekly
record keeping system to report his daily
progress on his MT home-based
program that is designed to increase his
LUE motor function and sensory
retraining.

How it addresses the performance

problem:

Therapy will include preparatory and

functional tasks aimed increase number
of repetitions the LUE receives to rebuild
neuropathways to the brain that will
improve LUE motor control. This will be
in preparation for typing where the client
will engage in motor learning to relearn
the motor skills required to type on a
keyboard. Additionally, sensory
retraining will be implemented to train
the brain what different sensations feel
like, thus rebuilding sensory function that
are strongly connected to motor function.
Music is added to the therapy session
b/c evidence supports auditory-motor
coupling, and emotion-motivation effects
 due to the playfulness and emotional
impact of music which will be useful in
MT to increase motivation, repetitions,
and motor function.

HOME EXERCISE PROGRAM - INTERVENTION PLAN FOR COMMUNITY CLIENT

Goals for the 3-week Break:

LTG 1: By discharge, the client will independently don socks, shoes, and AFO brace while incorporating his LUE
using compensatory strategies.

STG 1: In 2 weeks, the client will be able to don L shoe over heel while incorporating his LUE using compensatory
strategies with min A.

LTG 2: By discharge, the client will increase typing speed by 10 wpm while incorporating LUE using compensatory
strategies.

STG 1: In 2 weeks, the client will accurately use the shift key in 4/5 trials while incorporating his LUE using
compensatory strategies.
 OCCUPATIONAL
PERFORMANCE PROBLEM
Specifically identify only the client
factors and/or performance skills
that are barriers to the
achievement of this goal. This
should not be a bullet list, rather
you should describe how the client
factor impacts this client’s
performance of the occupation in
the goal.
OPM and CPM
AND RATIONALE
Identify your OPM and all relevant
CPM’s that best addresses the
performance problem and describe
how each will be used to design
treatment for this client’s specific
problems.
TREATMENT SESSION
DESCRIPTION
Provide details of how you will set up
the activity and how your intervention
addresses the performance problem.
Your description should detail how the
activity will be set up to make it
therapeutic.
GRADING THE ACTIVITY
Choose one client factor or
performance skill that you
address in your treatment
session. Describe one way
(only one) that you can grade
the activity up and one way
(only one) to grade the activity
down based on that one factor
or skill.

Client factors: OPM: PEO Activity Set Up: Factor/Skill: Control of

The client factors impacting the
client’s ability to type and/or
independently don his L shoe and
sock are minimal proprioception in
his hand, absent touch functions
(light touch), lack of control of
voluntary movement in his fine
motor skills and muscle tone (high
tone) resulting from the
hemiparesis effects of his R
thalamic hemorrhage. He has
difficulty feeling the laces and then
utilizing his fine motor control to tie
laces and grip to don sock and
shoe over heel.
The PEO Model will enable me to
create the most optimal solutions
for the client as I take each factor
(support and barrier) into
consideration to effectively modify
the task and environment as
needed to fit the client’s needs and
promote greater occupational
performance and participation.
Person: The client is a 69 y/o male
with a R thalamic hemorrhage
resulting in L hemiparesis, high
tone, extensor synergy, and soft
tissue shortening.
HEP Overall Therapy Outline:
1. Client-centered music
2. Mirror Therapy functional
sensory and motor retraining.
10-30 min/day, daily
3. Mental Imagery: listen anytime
everyday 10+ minutes/day
Supplies:
- Mirror Therapy supplies for 3-4
weeks
- Mental imagery audio
- Mental imagery highlighted
research
voluntary movement
Grade Up: Client will engage
LUE in fine motor control
preparatory and functional tasks
during Mirror Therapy.
Grade Down: Client will
observe his mirrored “LUE”
participating in preparatory and
functional tasks during Mirror
Therapy.

In typing he lacks light touch Environment: The environment is

sensation in his LUE making it very
difficult to feel when he is pressing
on the keys. Also because he has
minimal proprioception in his hand
he doesn’t notice when L finger
move positions, and his lack of fine
motor control makes it very difficult
to use dexterous movements
needed to effectively type, and
finally his abnormally high tone
due to his flexor synergy make it
difficult to not press on keys.
dressing in his home in preparation
for work and donning his shoes
back after showering to be able to
exit safely.
Occupation: Donning his L
sock/shoe
CPM: Motor Control/Learning
Model
Home Exercise Program (Part 1):
Mirror Therapy
Client will continue to implement mirror
therapy to gain repetitious movement to
rebuild neuropathways of functional
motor movements and sensory
retraining for more optimal LUE
function. Client will receive a list of
exercises and functional MT tasks as
homework. A LE MT program will also
be provided as per client’s request.
Home Exercise Program:
Performance Skills:
The performance skills currently
impacting the client’s performance
with the goal of donning his L sock
and shoe are positions, reaches,
grip, manipulates and coordinates.
Because of his L sided
hemiparesis, high tone, and overall
weakness he has difficulty
reaching down far enough with his
LUE and the lack of motor control,
create an inability to effectively grip
his sock/shoe to pull them on and
manipulate laces to tie them. He
also has difficulty positioning his
LUE because of a lack of
proprioception and light touch, he
cannot feel when his left hand is
touching the lacks to use his pincer
grip. Also, he has difficulty
coordinating his LUE along with his
right to pull on sock/shoe and tie
laces making task more difficult
and time consuming.
The performance skills impacting
the client’s ability to type are
manipulate and coordinate.
Because of his high tone, lack of
fine motor control, and extensor
tone resulting from his stroke, he
has difficulty with dexterous
movements of his individual
fingers.
The Motor Control/Learning Model
is important to implement b/c of the
client’s R thalamic hemorrhage
resulting in L hemiparesis. His
stroke caused a disruption in the
cortical connection between his
brain and motor movement of his L
side. The focus of treatment will be
to promote more repetitious motor
movements from the LUE to rebuild
motor pathways using Mirror
Therapy functional exercises.
Mirror Therapy
Upper extremity exercises:
i. Writing on paper write anything
you choose for 1-page
ii. Do individual finger raises – 15
reps
iii. Individual finger reaches – 15
reps
iv. Touch each finger to thumb – 15
reps
v. Brushing hair – see homunculus
brain mapping on back
vi. Choose 1 instrument to tap along
to the rhythm during several
songs (ex: follow the percussion
beat or guitarist strumming or
pianist in different songs you
choose)
vii. Sensory: Run hands through rice,
beans, sand
Lower extremity exercises (optional):
i. Ankle point & flex – 15 reps
ii. Toe-in & toe-out – 15 reps
iii. Ankle circles (R & L) – 15 reps
iv. Toe tap (rainbow back and forth)
– 15 reps
v. Eversion & inversion of ankle – 15
reps
vi. Sensory: Run feet through rice,
beans, sand
Home Exercise Program (Part 2):
Mental Imagery & Research Handout
Client will listen to a personalized
mental imagery audio daily during the
3-4 weeks break. Audio will guide client
through meaningful activities he has
expressed are difficult and has a desire
to improve (donning socks/shoes,
typing, and buttoning buttons, and
cutting food). The mental imagery will
be described vividly by combining the
visualization with as much sensory
information as possible, adding specific
details, and asking client to imagine
them in real time. Sensory details will
include feeling, hearing, smelling, and
tasting. While the therapist will provide
this mental imagery audio recording,
the client will be encouraged to write up
and record his own mental imagery
practice in his own voice to make it
more believable to his brain.

How HEP Will Be Therapeutic:

Mirror Therapy:
The existing evidence supports the
positive effects of mirror therapy in
stroke patients on the following
domains:
• Improving motor function and ADLs
• Reducing pain
• Reducing neglect
• Reducing sensory impairment

Mental Imagery/Practice (MP):

Mental imagery practice has shown to
improve motor function, increase
feelings of autonomy, and motivate
stroke patients to work even harder. MP
is where the same musculature and
neural structure are activated during
mental practice as during physical
practice of the same task. MP improves
movement via significant cortical
reorganization of the brain and create
observable motor change. Research
shows most changes were observed in
distal impairments (wrist extension and
pincer grasp). Subjects reported new
ability to perform components of ADLs.
These new abilities transferred to the
new ability to perform other important
ADLs. Also, MP increases affected arm
use and function even years after
stroke.

How HEP Addresses the

Performance Problem:
Mirror Therapy will include preparatory
and functional tasks aimed increase
number of repetitions the LUE receives
to rebuild neuropathways to the brain
that will improve LUE motor control.
This will be in preparation for later
engaging in fine motor functional tasks
of donning socks/shoe/AFO brace and
typing to relearn the motor skills
required to perform these and other
ADLs. Sensory retraining is part of MT
to visually observe the mirrored LUE
feel what the RUE is feeling to provide
training to the brain of what different
sensations feel like--thus rebuilding
sensory function that is strongly
connected to motor function.

Music is always added to therapy

sessions b/c evidence supports
auditory-motor coupling, and emotion-
motivation effects due to the
playfulness and emotional impact of
music which will be useful in MT to
increase motivation, repetitions, and
fine motor function.

The client will be guided through Mental

Imagery/Practice to encourage him to
visualize himself effectively using his L
fingers and hands in meaningful
occupational activities to improve LUE
fine motor function.