Date implemented:

Client’s Initials and Age: F.J., 62 y.o Time allotted for session: 60min
9/19/18
Diagnosis and any Precautions: (1) Healed laceration at PIP joint of R index finger, loss of sensory function
above PIP joint on radial side of index finger and decreased ROM of MCP, PIP, and DIP joints. Pt postures R index
finger in “pointed”, extended position which puts it at risk for further injury due to catching or hitting objects
unintentionally, especially since there is impaired sensation.
Goal/s being addressed: Increase sensory awareness for safe use of R hand in IADLs, increase fine motor coordination for independence in
ADL/IADL and leisure performance, increase ROM of PIP and DIP joints for functional use of R hand in ADL tasks, increase R hand grip strength
by 15lb to be WFL and symmetrical with L hand for increased independence in operating hand-held tools used in construction job.
Activity Demands (setting,
Specific Objectives for this Modifications (provided during the
Intervention Activities materials, and social
activity (list 2-3) activity and planned for next
(5) requirements)
(5) session) (5)
(5)
I was unable to implement the full treatment session because the pt arrived early in the morning on 9/19, prior to reviewing my treatment plan with
my CI, and I was assisting with another patient for part of F.J’s session. The plan was to implement my treatment activities with F.J the following
week on 9/26, but pt rescheduled for 9/27. No other pt presented to the clinic who was appropriate for these treatment activities, per CI opinion.
I was able to implement PROM, AROM, Thera-putty exercises, and the Bean Dig Activity with F.J.
Seated at table, hand resting on
Tolerance of ultrasound @ scar towel, ultrasound unit,
Modality-Ultrasound: ultrasound transmission gel,
3.3mgHz, 100% continuous cycle,  Pain scale
sterile alcohol prep wipe, verbal
0.5W/cm2  Report of painful
or nonverbal indication of pain or Therapist administered.
Applied to scar in an effort to sensation over scar
sensory stimulation during tx.
Decrease swelling at PIP:
breakdown scar tissue to allow for No modifications to be made, as the
 Girth measurement
increased ROM, decreased girth, Grade up: increase power ultrasound parameters were specific to
and potentially releasing entrapped (w/cm2) injury and location (superficial scar).
Relation to goals:
nerve fibers. Grade down: decrease time of
 Scar tissue management ultrasound if length is not
7min
 Increase ROM of PIP tolerated; use 50% cycle to allow
for rest periods
Tolerance of massage over scar Seated at table, lotion, hand
 Pain scale Therapist administered.
resting on towel, verbal or
Scar Massage:
 Report of painful nonverbal indication of pain or
“milking” of the finger in direction Modifications during activity: pt reported
sensation over scar sensory stimulation during tx.
of distal to proximal, squeezing Decrease swelling at PIP: increased sensitivity when massaging
the finger and rubbing the scar directly on scar, so less pressure was
 Girth measurement Grade Up: increase applied
in circular motions to encourage applied on the scar and more massage
pressure, apply slight stretch to
movement of fluids proximally was administered on the surrounding
Relation to goals: finger while massaging, pt
and breakdown of scar tissue areas.
 Edema management administer massage
3min
 Scar tissue management Grade Down: decrease amount
 Sensory stimulation of pressure being applied

Therapeutic Exercise:
Passive ROM of MCP, PIP, DIP
through flexion/extension,
holding at end range for 3
seconds, 10x per joint to guide
joints through max ROM
5min
Therapeutic Exercise:
Active ROM of MCP, PIP, DIP
through flexion/extension,
AB/Adduction, and composite
fist, holding at end range for 3
seconds, 10x per joint
5min
Rubber band Strumming:
Simulating strumming a guitar
string, 6 rubber bands of varying
thicknesses are strung between
2 bolts on the perforated box.
Using the right index finger to
pluck each string, moving
through full extension/flexion
ROM.
5min
Remembering to move through
full ROM at each joint with
quality
 # of verbal cues for
completing full ROM
Increase ROM at each joint
 Measure with goniometer
Relation to goals:
 Increased ROM
Increase ROM at each joint
 Measure with goniometer
Practice using own muscular
strength to move joints
 Measure with goniometer
 Time how long end range
position can be held
Relation to goals:
 Increased ROM
 Increase grip strength
Use index finger in isolation to
make contact with individual
bands
 # of strings able to pluck
 # of errors in band
selection
Able to react and adjust
movements/position of index
finger to be in correct placement
 # errors of band plucking
when given pattern
 Time how long it takes to
correctly complete
pattern
Seated at table with R elbow
resting on table. Therapist
provide feedback on pacing and
motion of each movement. May
have pt count out loud to track Pt performed all ROM independently, but
repetitions. therapist insert self to hold PIP and DIP
joints in further flexion once to remind pt
Grade Up: have pt or administer to try to achieve greater ROM.
ROM, hold at end range for
longer time
Grade Down: lay hand flat on
table to be gravity assisted
decrease # of repetitions
Seated at table with R elbow
No modifications needed to be made
resting on table. Therapist
aside from emphasizing the holding of
provide feedback on pacing and
end-range position for as long as
motion of each movement. May
tolerable.
have pt count out loud to track
repetitions.
Considerations for next visit: perform
ROM with hand supinated and parallel
Grade Up: apply resistance,
with table to increase gravity-pull
increase # of repetitions
challenge. Also, increase time that pt
Grade Down: lay hand flat on
holds end range positions before
table to be gravity assisted,
relaxing.
decrease # of repetitions
Seated at table, with perforated
box positioned on table in front
of pt, screws and nuts to act as
anchors for the rubber bands, 6
Unable to implement due to time
rubber bands of varying
constraints. OTR/L was excited about
thickness.
this idea and hopes to implement in next
session.
Grade up: color code each
rubber band, and have pt follow
Considerations for next session: have
a determined pattern for
the pt assemble the box and rubber
plucking the specific bands
bands, having to use FMC to screw the
bolts and nuts together and stretch the
Grade down: decrease the
bands prior to performing the strumming.
stretch/resistance of the bands
for easier plucking; increase
spacing between bands for less
precision of finger placement

Thera-putty exercises:
per Thera-putty Exercise Hand
Out, each repeated 5x. DIP/PIP
flexion, composite fist, thumb
adduction, index finger
adduction, index finger
extension against resistance,
digits 2-5 abduction, tripod grasp
and pull.
7min
Jenga:
Arrange and stack blocks in
rows of 3, using R hand for
grasping. Taking turns, remove
1 block at a time from the tower
and gently place on top. This will
encourage awareness of index
finger placement, functional use
of index finger with pinching,
and fine motor skills of
modulating force and precision
of finger use.
10min
Relation to goals:
 Increase ROM
 Increase FMC
 Sensory stimulation
Ability to perform ROM against
resistance
 # of reps completed for
each exercise
Relation to goals:
 Increase ROM
 Increase FMC
 Increase grip strength
Using the R index finger in point
position to isolate and remove
blocks
 # of blocks successfully
removed and replaced
using R index finger
Being aware of index finger
position in space
 Recording # of errors
where index finger was
not in normal movement
pattern or hit the blocks
unintentionally
Using tip-pinch to manipulate
blocks while stacking
Relation to goals:
 Increase FMC
 Sensory stimulation
Modified the Thera-putty Exercise
Seated at table surface, 2oz of
Handout to eliminate 2 thumb
soft yellow therapy putty, Visual
extension/abduction exercises that were
aid of Thera-putty Exercise
irrelevant to condition, and to change the
handout and/or verbal cueing
finger abduction exercise to involve all 4
from therapist, verbalization of
digits rather than just 2.
pain or unusual sensation.
During next treatment session, increase
Grade up: increase resistance
to the Red Thera-putty resistance as
level of thera-putty, increase # of
patient reported and demonstrated that
repetitions, have pt hold end
the yellow resistance was not providing
position
Grade down: decrease # of
much resistance against extension and
abduction movements. It may be
exercises completed, decrease
appropriate to still perform flexion
# of repetitions
movements with yellow thera-putty due
to nature of condition.
Seated at table, jenga game box
with ~54 blocks, clear, flat table
surface, communication with
opponent to coordinate stacking
and turns while playing, verbal
cueing from therapist for
positioning and movement Unable to implement due to time
patterns of index finger constraints.
Grade Up: insist on only R index
and thumb to be used
Grade Down: decrease # of
blocks used, allow for 2 hands to
remove and stabilize blocks

Tennis ball catching:
1- With hand pronated,
catching ball after
bouncing on floor, 10x
2- With hand supinated,
catching ball after
throwing upward, 10x
3- With hand in neutral
catching a toss thrown
by therapist, 10x
7min
Bean Dig Hunt:
With vision occluded, dig with R Efficient time to locate and
hand through bean bucket to
find specific items listed on
scavenger hunt.
7min
Describe the activity (one per
row) be specific and detailed.
Involving index finger in normal
cylindrical grasping patterns
Reaction time to grasp the
bouncing or falling ball
 # of times in a row the
ball is caught with correct
grasp (using index finger) Grade Up: decrease size or underhand toss, and/or bouncing on the
Relation to goals:
 Increase FMC
 Sensory stimulation
Relying on tactile sensation to
locate and identify objects
 # of correctly
located/identified objects of pain or unusual sensation
identify objects ( for safety)
 Time how long it takes to
locate objects
Relation to goals:
 Increased FMC
 Sensory stimulation
 Safety awareness
1 Tennis ball, open flat flooring
surface, chair, verbal cueing from
therapist about use of index Unable to implement due to time
finger for grasping and reaction constraints.
time, vocalization of pain or
unusual sensation The speed of the ball could be modified
by throwing to patient with a lighter,
change texture of ball, decrease floor with less force.
height of throw/bounce to
decrease reaction time During next session, attempt 3-finger
Grade down: perform standing to (tripod) grasps when catching the ball in
increase time of bounce before order to emphasize the flexion of the
grasping, allow for catching with index finger.
2 hands, buddy-tape index and
middle finger together
Seated in chair, bucket placed on
chair/stool at waist height, bucket
of pinto beans with ~10 small
items buried within (coins, jacks,
paper clips, erasers, marbles),
verbal prompting from therapist
to find certain items, vocalization
The patient was initially asked to find
specific items within the bucket (quarter,
Grade up: change substance of eraser, paper clip, jack), but when that
bucket (rice, marbles, corn proved too difficult, the activity was
kernels), decrease size, change modified to just have pt find any items he
texture, increase quantity of could. Then had the pt pick up the found
objects, be specific on finding items using tip-pinch grasp and re-burry
certain items, time how long it them back in the bucket.
takes to find items
Grade down: increase size of
objects, decrease quantity of
objects, allow for both hands in
bucket, don’t be specific on what
object is found, decrease amount
of bean substance
What went well, what not so well, what
will you do next time? Did you change
 Give estimated time per activity.
Need enough activities listed to
fill the time (probably 2-4).
Why did you choose this
activity? (clinical reasoning)
List 1-2 specific objectives per
activity that you plan to measure
during client performance.
List the materials that you will
need and how you will set up the
environment and activity.
State 2 ways to grade/adapt the
activity or environment.
something during the session? How can
you better support the client’s
performance or get more effort and skill
from the client.

S/OT name: Shannon Joyce

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)

“Digital nerves are the most frequently injured peripheral nerve. To improve the recovery of functional sensibility of digital nerve injuries, a
prospective randomized controlled study was conducted to see the effect of using early tactile stimulation in rehabilitation of digital nerve injuries.
Two specific tactile stimulators were made and prescribed for patients with digital nerve-injury. Twenty-four participants with 32 digital nerve injuries
received the prescribed tactile stimulators (experimental group), and another 25 participants with 33 digital nerve injuries received only routine
conventional therapy (control group). A significant difference (p < .05) was seen in the experimental group, although there were some variations
between the different classes of associated injuries, with least benefit observed in the combined nerve, tendon, and bone injury class. Use of early
tactile stimulation as described in this study can be considered an effective way to improve both quality and quantity of recovery of functional
sensibility in digital nerve injuries without combined nerve, tendon, and bone injuries.”

Cheng, A. S.-K. (2000). Use of early tactile stimulation in rehabilitation of digital nerve injuries. American Journal of Occupational Therapy, 54, 159–
165.

Justification:
This article studied whether or not incorporating tactile sensory stimulation in therapy sessions made a difference for in the recovery of functional
sensation following nerve injuries to the finger digits. This directly relates to this client as this client is experiencing lack of sensation in the R index
digit following a finger laceration and nerve injury 6 weeks ago, and one of the client’s goals is to increase sensory awareness for functional use and
safety during ADL/IADL tasks. This study provides evidence that incorporating tactile sensory stimulation activities during treatment may impact the
return of tactile sensory function, as well as the quality of that sensation.

Total: 27 points