Client’s Initials and Age: D.K.; 60 yrs old Time allotted for session: ~20 min.

(plus time to get Date implemented:

to/from therapy gym) 8/19/21
Diagnosis and any Precautions: (1) L CVA and R hemiplegia, expressive aphasia, labial wound, pre-
existing shoulder conditions
Goal/s being addressed: (1) functional use of RUE
Activity Demands (setting,
Specific Objectives for this Modifications (provided during
Intervention Activities materials, and social
activity (list 2-3) the activity and planned for next
(5) requirements)
(5) session) (5)
(5)
(5 min) Stretching of the Stretching will be done at a No major modifications were
RUE: 1. After being stretched, table that will be adjusted to made to D’s stretching except that
1. D will be seated with D’s R arm will rest in sit at the appropriate height. she stayed seated in her wheelchair
her RUE resting on a a less-flexed position D will be seated in her tilt- since it has arm support.
table to her right at as indicated by her in-space wheelchair to the Additionally, we could stay near
shoulder height. arm resting on her arm left of the table so her RUE the mat that was used for the next
2. Therapist will move rest in 90 degrees of rests comfortably. The entire activity to save time instead of
D’s upper extremity in elbow extension or session will take place in a moving between table and mat.
passive range of less. Additionally, her therapy gym of moderate D’s elbow was especially tight
motion to warm up fingers will lay flat on busy-ness but D shows no today so she could have used more
muscles briefly before the table. D will not signs of distress in crowded stretching time. At least 10
beginning stretches. feel any pain. places. Therapist will be minutes would be helpful for the
3. Therapist stretches D’s 2. After stretching, D aware of her aphasia and next session. After all stretching
elbow at pain-free end will have more fluid- best ways to communicate was complete, gentle and slow
range of motion for 2 like movements with pain (yes/no questions). PROM of the shoulder and scapula
minutes. limited spasticity that was done to observe movements
4. Therapist stretches D’s allow for appropriate Grade/adapt: more or less she had in preparation for the
wrist into extension at neuro reeducation. stretch to get closer/farther intervention activity. Even though
pain-free end range of 3. D will have increased from end-ranges of ROM D is non-verbal, she can answer
motion for 2 minutes. passive ROM after all (pain dependent); addition of yes or no questions so I could
5. Therapist stretches D’s stretching is complete. heat; more PROM before make sure I was within a pain-free
fingers into extension It is imperative to stretches ROM.
at pain-free end range watch D’s face for any
 of motion each for ~10
seconds.
Since D has hypertonicity and
spasticity in her RUE (most
pronounce din bicep and
wrist), spending time at the
beginning of the session to
stretch out her affected
muscles (excluding shoulder
due to pre-existing condition).
Lengthening these muscles
will help prevent contracture
and ease the tightness that
keeps her elbow, wrist and
fingers in flexion.
(15 min) PNF Pattern Ring
Grasping:
1. D will be seated EOB
facing the therapist.
2. D’s RUE will be
positioned next to her
to weight bear through
it.
3. While keeping good
dynamic sitting
balance, D will use her
LUE to reach up and
diagonally for a with hand over hand
weighted ring and
place it down on the
target by her right
knee (PNF D1
signs of pain. Due to
her aphasia, we must
be careful to not go
past her pain threshold
as indicated by facial
expressions, or her
specific verbals
(“mommy”).
1. D will be stable while There needs to be two Quite a few modifications were
weight bearing therapists present in order made for this activity that made it
through the opposite for D to complete this task flow well and stay within time
arm while grasping for with her RUE. Rings and limits. Firstly, instead of weight
the ring. target are needed and a bearing through her wrist on the
2. D will demonstrate stable mat for her to sit on mat, a bolster was added to create
fluid movements in the the edge. about a 6 inch height that she
D1 and D2 PNF could keep her wrist. This gave
patterns even if ROM Grade/adapt: move target more control. A second therapist
is limited. closer or farther away to stabilized her elbow with
3. While performing this encourage less or more maximum assistance. We only
activity with her RUE diagonal movements; used 6 rings for the sake of time
reaching up in different and did not perform the D2
assistance, the planes to encourage core movements. During the activity, I
therapist will be able stabilization in various could move the target further away
to lead D through a directions when I noticed she was not
ROM similar to what reaching far to place it. The second
 pattern). Repeat 10
times before taking a
break and repeating in 4. D’s core will be
the opposite direction
(PNF D2 pattern). D
will be weight bearing
in her RUE to keep her
balance while seated
EOB.
4. With the help of an
aid, therapist will use
hand over hand
assistance to do the
same activity with D’s
RUE (diagonal
reaching and grasping)
5 times before
repeating in the
opposite direction. Ds
will be weight bearing
in her LUE.
was observed during time through, D kept her arm on
the stretches. the bolster but in a flexed elbow
position with moderate support
engaged during the from the therapist. Lastly, D was
activity as to keep her confused by the concept of weight
sitting balance better. bearing through her left arm and
participating with her R.
Therefore, we focused on dynamic
sitting balance and core control
while I provided hand over hand
assistance to bring RUE towards
rings at different heights in front
of her and place on target directly
below. This allowed greater focus
on solely neuro-reeducation
component of her affected arm.

D has very little use of her

RUE. When positioned on the
mat, she will be able to weight
bear through that arm in order
to reach for the rings with her
opposite arm. This gives great
sensory input into her
shoulder and upper extremity
which she otherwise lacks.
This will help ‘awake’ her
muscles in that limb. By
 engaging in PNF patterns, D
is using almost all muscles in
her upper extremity to reach
for the weighted ring and
bring it back. During these
movements, D’s core is
engaged, too. Additionally,
since these PNF patterns are
neurodevelopmental, they are
useful for a case like D since
she is starting with no use at
all of her RUE. Starting with
basic movements will be a
strong first step before
moving into more complex
movements of the limb.
S/OT name: Leila Salhi
Find one peer-reviewed article that supports the intervention you planned/provided. At the bottom of your plan, paste the
abstract and citation and then in your own words describe how this supports your intervention plan. (5)

Total: 27 points

Peer Reviewed Article + Support

Citation: Tseng, C.-N., Chen, C. C.-H., Wu, S.-C., & Lin, L.-C. (2007). Effects of a range-of-motion exercise programme. Journal of
Advanced Nursing, 57, 181–191. https://doi.org/10.1111/j.1365-2648.2006.04078.x

Title: Effects of a range-of-motion exercise programme

Aim. This paper reports an evaluation of a range-of-motion exercise programme aimed at improving joint flexibility, activity function,
perception of pain, and depressive symptoms in a sample of stroke survivors in long-term care facilities.

Background. The benefits of physical rehabilitation for stroke survivors have been well established. There is, however, little
empirical data on the effects of a simple nurse-led range-of-motion exercise programme in improving function for these people.

Method. A randomized controlled trial was conducted in 1999 with 59 bedridden older stroke survivors in residential care.
Participants were randomly assigned to usual care or one of two intervention groups. The 4-week, twice-per-day, 6 days-per-week
range-of-motion exercise protocols were similar in both intervention groups, and consisted of full range-of-motion exercises of the
upper and lower extremities. To test the effect of different degrees of staff involvement, in intervention group I, a Registered Nurse
was present to supervise participants performing the exercises, while intervention group II involved a Registered Nurse physically
assisting participants to achieve maximum range-of-motion within or beyond their present abilities.

Results. Both intervention groups had statistically significant improvement in joint angles, activity function, perception of pain and
depressive symptoms compared with the usual care group (P < 0·05). Post hoc comparison revealed that the joint angles in
intervention group II were statistically significantly wider than in both the other groups (P < 0·01).

Conclusions. A simple nurse-led range-of-motion exercise programme can generate positive effects in enhancing physical and
psychological function of bedridden older people with stroke. Further studies are needed to investigate the long-term effects of the
programme in maximizing function, reducing care utilization and enhancing quality of life for this population.
Support: Stretching as part of a ROM exercise program was shown to improve joint angles, activity function and perception of pain
compared to the control group. These areas are specifically where D has deficits and improvements here will increase the overall
functionality of her hand in the future by giving her ability to complete ADLs with both hands. This study was completed on stroke
patients with poststroke spasticity therefore the study population is relevant to D, too. The study’s two intervention groups
(supervision during patient’s own stretching routine, or stretching protocol performed by nursing staff). The latter showed the most
improvement supporting my stretching of D’s limb instead of her performing it on her own.