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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
Seated at table with R elbow
Remembering to move through resting on table. Therapist
full ROM at each joint with provide feedback on pacing and
Therapeutic Exercise: quality motion of each movement. May
Passive ROM of MCP, PIP, DIP have pt count out loud to track Pt performed all ROM independently, but
 # of verbal cues for
through flexion/extension, repetitions. therapist insert self to hold PIP and DIP
completing full ROM
holding at end range for 3 joints in further flexion once to remind pt
Increase ROM at each joint
seconds, 10x per joint to guide Grade Up: have pt or administer to try to achieve greater ROM.
 Measure with goniometer
joints through max ROM ROM, hold at end range for
5min longer time
Relation to goals:
Grade Down: lay hand flat on
 Increased ROM table to be gravity assisted
decrease # of repetitions
Increase ROM at each joint Seated at table with R elbow
 Measure with goniometer No modifications needed to be made
resting on table. Therapist
aside from emphasizing the holding of
provide feedback on pacing and
Therapeutic Exercise: Practice using own muscular end-range position for as long as
motion of each movement. May
Active ROM of MCP, PIP, DIP strength to move joints tolerable.
have pt count out loud to track
through flexion/extension,
 Measure with goniometer repetitions.
AB/Adduction, and composite Considerations for next visit: perform
 Time how long end range
fist, holding at end range for 3 ROM with hand supinated and parallel
position can be held Grade Up: apply resistance,
seconds, 10x per joint with table to increase gravity-pull
increase # of repetitions
5min challenge. Also, increase time that pt
Relation to goals: Grade Down: lay hand flat on
holds end range positions before
 Increased ROM table to be gravity assisted,
relaxing.
 Increase grip strength decrease # of repetitions
Use index finger in isolation to Seated at table, with perforated
make contact with individual box positioned on table in front
bands of pt, screws and nuts to act as
 # of strings able to pluck anchors for the rubber bands, 6
Rubber band Strumming: Unable to implement due to time
 # of errors in band rubber bands of varying
Simulating strumming a guitar constraints. OTR/L was excited about
selection thickness.
string, 6 rubber bands of varying this idea and hopes to implement in next
thicknesses are strung between session.
Able to react and adjust Grade up: color code each
2 bolts on the perforated box.
movements/position of index rubber band, and have pt follow
Using the right index finger to Considerations for next session: have
finger to be in correct placement a determined pattern for
pluck each string, moving the pt assemble the box and rubber
 # errors of band plucking plucking the specific bands
through full extension/flexion bands, having to use FMC to screw the
ROM. when given pattern bolts and nuts together and stretch the
5min  Time how long it takes to Grade down: decrease the
bands prior to performing the strumming.
correctly complete stretch/resistance of the bands
pattern for easier plucking; increase
spacing between bands for less
precision of finger placement
Relation to goals:
 Increase ROM
 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
Thera-putty exercises: Ability to perform ROM against aid of Thera-putty Exercise
irrelevant to condition, and to change the
per Thera-putty Exercise Hand resistance handout and/or verbal cueing
finger abduction exercise to involve all 4
Out, each repeated 5x. DIP/PIP from therapist, verbalization of
 # of reps completed for digits rather than just 2.
flexion, composite fist, thumb each exercise pain or unusual sensation.
adduction, index finger
During next treatment session, increase
adduction, index finger Grade up: increase resistance
Relation to goals: to the Red Thera-putty resistance as
extension against resistance, level of thera-putty, increase # of
 Increase ROM patient reported and demonstrated that
digits 2-5 abduction, tripod grasp repetitions, have pt hold end
 Increase FMC the yellow resistance was not providing
and pull. position
7min  Increase grip strength 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.
Using the R index finger in point
position to isolate and remove
blocks
 # of blocks successfully
removed and replaced Seated at table, jenga game box
Jenga:
with ~54 blocks, clear, flat table
Arrange and stack blocks in using R index finger
surface, communication with
rows of 3, using R hand for
opponent to coordinate stacking
grasping. Taking turns, remove Being aware of index finger
position in space and turns while playing, verbal
1 block at a time from the tower
cueing from therapist for
and gently place on top. This will  Recording # of errors
positioning and movement Unable to implement due to time
encourage awareness of index where index finger was
patterns of index finger constraints.
finger placement, functional use not in normal movement
of index finger with pinching, pattern or hit the blocks
Grade Up: insist on only R index
and fine motor skills of unintentionally
and thumb to be used
modulating force and precision
Grade Down: decrease # of
of finger use. Using tip-pinch to manipulate
blocks used, allow for 2 hands to
10min blocks while stacking
remove and stabilize blocks
Relation to goals:
 Increase FMC
 Sensory stimulation
Involving index finger in normal 1 Tennis ball, open flat flooring
cylindrical grasping patterns surface, chair, verbal cueing from
therapist about use of index Unable to implement due to time
Tennis ball catching:
Reaction time to grasp the finger for grasping and reaction constraints.
1- With hand pronated,
bouncing or falling ball time, vocalization of pain or
catching ball after
 # of times in a row the unusual sensation The speed of the ball could be modified
bouncing on floor, 10x
ball is caught with correct by throwing to patient with a lighter,
2- With hand supinated,
catching ball after grasp (using index finger) Grade Up: decrease size or underhand toss, and/or bouncing on the
change texture of ball, decrease floor with less force.
throwing upward, 10x
Relation to goals: height of throw/bounce to
3- With hand in neutral
catching a toss thrown  Increase FMC decrease reaction time During next session, attempt 3-finger
by therapist, 10x  Sensory stimulation Grade down: perform standing to (tripod) grasps when catching the ball in
increase time of bounce before order to emphasize the flexion of the
7min
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,
Relying on tactile sensation to paper clips, erasers, marbles),
locate and identify objects verbal prompting from therapist
 # of correctly to find certain items, vocalization
located/identified objects of pain or unusual sensation The patient was initially asked to find
Bean Dig Hunt: specific items within the bucket (quarter,
With vision occluded, dig with R Efficient time to locate and Grade up: change substance of eraser, paper clip, jack), but when that
hand through bean bucket to identify objects ( for safety) bucket (rice, marbles, corn proved too difficult, the activity was
find specific items listed on kernels), decrease size, change modified to just have pt find any items he
 Time how long it takes to
scavenger hunt. texture, increase quantity of could. Then had the pt pick up the found
locate objects
7min objects, be specific on finding items using tip-pinch grasp and re-burry
Relation to goals:
certain items, time how long it them back in the bucket.
 Increased FMC
takes to find items
 Sensory stimulation Grade down: increase size of
 Safety awareness 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

Describe the activity (one per What went well, what not so well, what
row) be specific and detailed. will you do next time? Did you change
Give estimated time per activity. List 1-2 specific objectives per List the materials that you will something during the session? How can
Need enough activities listed to activity that you plan to measure need and how you will set up the you better support the client’s
fill the time (probably 2-4). during client performance. environment and activity. performance or get more effort and skill
Why did you choose this from the client.
activity? (clinical reasoning) State 2 ways to grade/adapt the
activity or environment.

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