User:Jun Mapili

Ipreval

Patient requires skilled physical therapy to address the following clinical problems: gait deficit, muscle weakness affecting mobility, equilibrium or balance deficit, pain interfering with movements, tenderness, muscle spasm, muscle guarding, and high risk of falling. Patient’s current functional deficit will not result in spontaneous functional recovery, thus necessitating skilled therapy intervention.

Patient necessitates skilled physical therapy to address the following clinical findings and impairments: muscle weakness affecting mobility, balance deficit, lack of muscular coordination, pain interfering with movements, tenderness, muscle spasm, muscle guarding, and high risk of falling. Patient’s current functional deficit will not result in spontaneous functional recovery, thus necessitating skilled therapy intervention.

Patient needs intensive rehabilitation program that necessitates multi-disciplinary coordinated team approach to improve functional ability. Patient is expected to improve in a reasonable and generally predictable period of time. Patient’s present functional deficits will not result in spontaneous functional recovery, thus necessitating skilled therapy intervention.

Patient requires intensive rehabilitation program that requires multi-disciplinary coordinated team approach to upgrade patient's functional ability. Patient is expected to improve in a reasonable and generally predictable period of time. Patient’s present functional deficits will not result in spontaneous functional recovery, thus necessitating skilled therapy intervention.

Patient is reasonably expected to actively participate and benefit significantly from the intensive rehabilitation therapy program based on the clinical assessment in which the patient’s condition and functional status described in this assessment are such that the patient can reasonably be expected to make measurable improvement, expected to be made within the prescribed period of time as a result of the intensive rehabilitation therapy program, that will be of practical value to improve the patient’s functional capacity or adaptation to impairments. Patient’s current functional deficit will not result in spontaneous functional recovery necessitating skilled therapy intervention.

Patient recently exhibited notable deterioration in bed mobility, transfers, and gait to______due to the medically complex conditions. Patient necessitates intensive skilled therapy interventions that can be provided on a daily basis through IPR in view of the patient's inability to return home safely secondary to high risk of falling as evidenced by the Tinetti score of ___in the functional outcome, unable to return home safely due to marked impairment in the patient's ability to perform functional mobility, patient needs 24-hour medical services that cannot be provided in home health care setting due to the intermittent criteria, inadequate/ insufficient help from caregiver, remarkable taxing effort to be in an out-patient therapy, [[unable to navigate stairs in order to enter/exit home safely]. Patient’s current functional deficit will not result in spontaneous functional recovery necessitating skilled therapy intervention. Patient is not anticipated to spontaneously improve functionally requiring skilled physical therapy interventions in order to address functional deficits.

Patient continues to require an intensive rehab therapy intervention through inpatient rehab and coordinated interdisciplinary team approach with the delivery of rehabilitative care. The functional assessment indicates that the patient is making functional improvements that are ongoing, sustainable, and of practical value, as measured against the patient’s condition at the start of treatment.

Beau

Prog

Patient was treated today with skilled physical therapy to address muscle weakness and impaired balance in order to improve bed mobility, transfers and gait. Patient was able to comprehend and follow __ step direction. Patient requires ___ with bed mobility, transfers and gait with the use of 2-wheeled walker. Patient needs verbal instructions, tactile feedback to improve safety. Patient was educated with postural awareness, trunk control and stability training, proper breathing techniques.
Patient was seen today with skilled physical therapy with focus on safety techniques and to address muscle weakness and impaired static and dynamic standing balance to improve functional mobility. Patient was able to comprehend and follow __ step direction. Patient requires ___ with bed mobility, transfers and gait with the use of 2-wheeled walker. Patient was educated with postural awareness, trunk control and stability training, proper breathing techniques.
Patient was seen and physical therapy treatment was rendered to rehabilitate the patient's decline in function secondary to ____. Patient followed ___ step command 100% of the time. Patient needs __with bed mobility, transfers and gait. Anticipate continued necessity for further education and training to improve safe functional mobility. The provision of skilled physical therapy in acute setting will decrease the length of stay through early mobility while observing medical precautions in order to safely prepare the patient prior to hospital discharge.
Patient was seen and treated today due to deterioration of function secondary to muscle weakness in bilateral UE/LE graded ____. Patient also presents with static and dynamic standing balance deficit requiring further training to improve level of function and to decrease risk of falling. Patient is pleasant and cooperative with the treatment. Patient requires __with bed mobility, transfers and gait. Patient will benefit from rehabilitative services with progressive functional training and with skilled physical therapy interventions.
Patient was able to verbalize correctly the 2 patient identifiers (name and date of birth) prior to treatment. Patient was assessed and treated today with skilled physical therapy due to _______. Patient followed ___ step direction 100% of the time. Patient requires __with bed mobility, transfers and gait. Patient will benefit with continued skilled therapy
- Patient requires verbal instructions, visual and proprioceptive feedback 50% of the time for proper technique of execution and for reduction of compensation.
- Patient requires external verbal cues __50% to improve the body’s output for mobility and functional outcomes as well as internal verbal feedback to improve processes and internal systems (muscles, kinematics), visual input to improve movement orientation with demonstrations and through kinesthetic/motor imagery.
- Patient needs tactile and verbal instructions 50% of the time for logroll to maintain neutral spine and avoid counter-rotation of the lumbar spine.
- Patient requires visual and auditory feedback _% to have proper hand or foot placement during mobility transition for recognition of precautions/barriers and feedback to successfully perform functional mobility safely.
- marked deficit in moving around in bed with scooting, bridging, bed rolling side to side and moving from lying to sitting and sitting to lying; sit to stand and bed< > chair transfers; ambulate on level surface and negotiating steps
- Patient was educated on signs and symptoms of activity intolerance, activity pacing, and self-monitoring with activity. Patient performed functional mobility (including bed mobility, transfers and gait) with verbal instructions, sequencing, hand/ft placement, safety techniques and physical assist as needed.

Eval

Patient was evaluated and treated today with skilled physical therapy to assess safety and to ___. Patient followed ___ step command 100% of the time. The patient's ability to learn and retain new information is (((guarded, fair, good)))). Patient requires __with bed mobility, transfers and gait. Patient verbalized understanding with the physical therapy plan of care including progressive activity. Anticipate continued necessity for further education and training.
Patient was referred for physical therapy evaluation and treatment to assess safety and decline in functional mobility. Patient followed ___ step command 100% of the time. The patient has (((excellent, good, fair)))) insight into disability and able retain new information. Patient requires __with bed mobility, transfers and gait. Patient will benefit from rehabilitative services with progressive functional training.
Patient was referred to acute physical therapy rehabilitation due to muscle weakness ---------. Patient developed a substantial decline in bed mobility, transfers and gait due to the medically complex conditions requiring skilled interventions. Clinical objective problems include: gait deficit, muscle weakness affecting mobility, equilibrium or balance deficit, dyspnea with minimal exertion, postural instability, pain interfering with movements, tenderness, muscle guarding, and high risk of falling. These clinical problems have resulted in significant/notable functional deterioration, as evidenced by a remarkable deficit in sit <-> stand and bed <-> chair transfer, bed mobility, gait on level surface, (((navigating stairs))) necessitating skilled physical rehabilitation.
Physical therapy will address inadequate hip/knee/ankle control and stability, inadequate postural control, inadequate weight acceptance, reduced amplitude of automative movements, decreased gait velocity, impaired turning, decrease step length/stride length, insufficient heel strike, diminished alternating movements, diminished anticipatory reactions, impulsive gait momentum, prolonged double support during gait, inconsistency and arrhythmicity in steps and arm movements, decrease motor control of the ___, impaired maneuvering around obstacles, decreased proactive balance,
Clinical objective findings include: gait deficit, deficits in trunk stability, muscle weakness in BUE/LE affecting mobility, equilibrium or balance deficit, pain interfering with movements, tenderness, muscle guarding, and high fall risks.
These clinical problems have resulted in a significant functional deterioration, as evidenced by a remarkable deficit in sit <-> stand and bed <-> chair transfer, bed mobility, gait on level surface, (((navigating stair))] requiring skilled physical rehabilitation. No adverse reaction during or after the treatment. The patient actively participated with the (((evaluation and))) treatment.
Patient's functional mobility is guarded, laborious, primarily requires ___ assist with bed mobility, transfers and gait.
The functional loss is not transient and will not spontaneously improve without skilled physical therapy services.
The patient's functional loss is expected to improve significantly only with skilled therapy in a reasonable and generally predictable period of time.
The unique clinical condition of the patient requires the specialized skills of a qualified therapist in order to improve function.
Patient functional mobility training requires a level of complexity and sophistication due to the patient's high risk of falling and the services can only be performed by or under the supervision of a therapist.
Physical therapy services will improve the patient's functional outcomes and will improve safety to decrease risk of falling/injury.
Physical therapy will provide reasonable, effective treatments for the patient’s condition which require the skills of a therapist. A delay in provision of therapy services until the patient arrives in the discharge setting may negatively impact the patient’s outcomes and at risk of re-hospitalization.
Equilibrium tests indicated the following: able to stand statically with _impairment, stand with vision occluded with _ impairment, stand with feet together with _impairment, stand on one foot _impairment, standing with alternate forward trunk flexion _impairment, march in place with _impairment, standing lateral trunk flex to each side _impairment, walking on a straight line _impairment, walking backwards _impairment, walking side ways _impairment, heel to toe in standing _impairment, tandem walking _impairment, walk in circle _impairment, walk in alternate directions, walk and then stop and start abruptly.

Precautions

KNEE replacement: Patient was instructed to elevate the affected limb to minimize swelling, perform ankle exercises for DVT prophylaxis, deep breathing exercises for basal atelectasis. Patient was educated not to twist on the operated leg and not to kneel. Patient was instructed to report any of the following: increase pain in the operative site, increase redness or warmth, or swelling and also to report if calf becomes swollen, tender, warm, or reddened.
KNEE replacement: Patient was instructed of edema control following surgery in order to decrease pain and swelling; report any evidence of infection such as redness, heat in joint, and persistent swelling; take a small step when turning; ice after exercise with the knee flat and elevated; do ankle pumps hourly and knee ROM three times a day. Patient was also instructed to never pivot or twist the operated leg, do not sit on low chairs since it may be difficult to get up and never put pillow under the leg.
KNEE replacement: Patient was instructed of edema control following surgery in order to decrease pain and swelling; report any evidence of infection such as redness, heat in joint, and persistent swelling; take a small step when turning; ice after exercise with the knee flat and elevated; do ankle pumps hourly and knee ROM three times a day. Patient was also instructed to never pivot or twist the operated leg, do not sit on low chairs since it may be difficult to get up and never put pillow under the leg.
KNEE Replacement: Patient was instructed with strategies to control edema on the affected limb to decrease swelling, ankle exercises for DVT prophylaxis, coughing tech and deep breathing exercises for basal atelectasis. Patient was also provided with instruction not to twist on the operated leg and to report any increase pain on the surgical site, increase redness or temp, or swelling.
HIP Replacement: Patient was instructed with safe progressive activity and functional mobility. Patient was educated in recognizing potential complications such as blood clots, joint dislocation, and infection. Patient was educated with the warning signs of blood clots like pain in the calf and leg that is unrelated to the incision, tenderness or redness of the calf, new or increasing swelling of the thigh, calf, ankle, or foot.
HIP Replacement: Patient was educated with the warning signs of pulmonary embolism, when a blood clot has traveled to the lung include: sudden shortness of breath, sudden onset of chest pain, localized chest pain with coughing. Patient was also instructed with warning signs of infection such as shaking chills, persistent fever (higher than 100 degrees, wound drainage, increasing redness, tenderness or swelling on the wound, increase pain with activity and rest.
HIP Replacement: Patient was instructed to report pain or discomfort that is sharp or does not go away with rest, rapid joint swelling or bleeding from incision. Patient was instructed not to bend trunk forward more than 90 deg, Do not lift the knee higher than the hip, Do not cross the legs at knees or ankles, do not rotate the operated legs.
HIP Precautions: Patient was instructed not to sit in the same position for more than 30 to 40 minutes at a time; keep the feet about 6 inches (15 centimeters) apart; do not cross the legs; keep the feet and knees pointed straight ahead, not turned in or out; sit in a firm chair with a straight back and armrests (avoid soft chairs, rocking chairs, stools, or sofas); avoid chairs that are too low (the hips should be higher than the knees when sitting; when getting up from a chair, slide toward the edge of the chair, and use the arms of the chair for support.
SPINE Precautions: Patient was instructed to always log roll to get out of bed and have a pillow between the knees for comfort and to help maintain precautions. Instructed not to lift more than 10 pounds and explained that a 12-pack of soda is 10 pounds, gallon of milk is 8.8 pounds, 2 liters of soda is 7.8 pounds, large saucepan is 1 pound; do not bend forward at the waist more than 90º or raise knees higher than hips, do not twist trunk while performing any activity.
SPINE Precautions: Patient was educated not to reach, stoop or bend forward at the waist more than 90 degrees; do not bend from side to side; do not lift anything heavier than 5 to 10 pounds and cited that a gallon of milk weighs about 8 pounds; hold objects lifted close to the body; do not bend forward or squat down to pick up items off of the floor; do not twist the spine when turning (shift the feet to turn the whole body instead; log roll to turn over in bed. Instructed to place pillows between the knees to keep the legs apart to keep the hips, pelvis and spine in alignment.
SPINE Precautions: Patient was instructed the proper way of getting out of bed by logrolling onto the side to avoid twisting. Patient was instructed to utilize the upper hand until able to support on the lower elbow then as the shoulders lifted off the bed to allow the feet to drop down from bed. Patient was also instructed getting into the bed by lowering self to the side onto the elbow while bringing the feet up to the bed at the same time then lower the body onto the shoulder and then log roll.
SPINE Precautions: Patient was instructed NOT to perform the following without physician's approval or clearance: straight leg raise, long arc quads, pelvic bridging, single or double knee to chest, hip extension, any resisted arm exercises, posterior pelvic tilt,repeated gluteal activities, NU step/bike, stretching LE. Patient was instructed wear brace when sitting, standing and walking until surgeon allows to wean off brace.
Cervical Spine: Instructed with cervical precautions and proper posture; stress that upper trapezius and other cervical musculature will need to actively relaxed frequently to decrease overuse. Transfer training (bed mobility, sit to/from stand) and instructed to practice log roll technique, self position in bed from side lying, sit to stand from various height surfaces with focus on posture, precautions and assist for safety as needed. Instructed with Brace management to practice technique to safely doff and don collar and instructed to switch front for front, back for back, one half at a time. Gait training on level surface with emphasis on frequent safe gait on a controlled environment.
Cervical Spine: Instructed with cervical precautions and how functional movement and activities will be impacted and may be needed to modify, patient verbalize and or return demo. Brace management training with don and doff, progress with gait training with focus on fall prevention and safe identified home and verbalized understanding.

Progress

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VS prior to treatment= BP: mmHg, PR: bpm, RR: cpm, SpO2: % room air, RPE: /10, Dyspnea Scale: /4
VS immediately after gait = BP: mmHg, PR: bpm, RR: cpm, SpO2: % room air, RPE: /10, Dyspnea Scale: /4
Recovery VS after 5 mins= BP: mmHg, PR: bpm, RR: cpm, SpO2: % room air, RPE: /10, Dyspnea Scale: /4
Patient demonstrates functional improvement with skilled physical therapy interventions comparing the clinical data from the initial physical therapy evaluation on ____ to the current physical therapy progress note ( ) as evidenced by the objective progress. Patient requires further skilled physical therapy interventions to improve level of function, achieve long term goals, and to be able to return to home safely.
Patient exhibits partial but reasonable progress with the provision of skilled physical therapy treatment based on the clinical data from the initial physical therapy evaluation on ____ in comparison to the current physical therapy progress note on ___ as evidenced by the objective and functional progress. Patient requires further skilled physical therapy interventions to decrease risk of falling, improve level of function, attain/accomplish long term goals, and to be able to return to home safely without injury or increase risk of re-hospitalization.
Patient presents partial functional improvement with the participation skilled physical therapy program based on the objective data from the initial physical therapy evaluation on ____ against the current physical therapy progress note on ___ as validated by the functional progress. Patient needs further skilled physical therapy interventions to attain/accomplish long term goals, decrease risk of falling, improve level of function, and to be able to return to home safely without increase risk of re-hospitalization.
The patient's active participation with the skilled physical therapy treatment showed improvement both in the clinical and functional aspects based on the objective data from the initial physical therapy evaluation on ____ against the current physical therapy progress note on ___ as substantiated by the functional progress. Patient needs further skilled physical therapy interventions to accomplish the long term goals, decrease risk of falling, improve level of function, and to be able to return to home safely without increase risk of re-hospitalization.
“Practical Matter” Justification:

Patient requires further skilled physical therapy treatment on a daily basis and can be provided, as a practical matter, only on an inpatient basis in a SNF secondary to the patient’s inability to return home safely due to the following reasons:

patient needs 24-hour aide services that cannot be provided in home health care setting due to the intermittent criteria,

patient will return to live alone,

inadequate/ insufficient assistance from caregiver, primary caregiver has ____ limiting the the assistance to be provided to the patient,

caregiver can only provide verbal instruction and unable to provide physical assist,

Patient’s spouse is unable to effectively physically assist the patient because of medically complex condition,

unable to navigate __ stairs in order to enter/exit home safely,

unable to ascend/descend __ stairs to the bedroom and bathroom,

high risk of falling (see standardized test),

sub-acute medical condition related to ____ with high risk of re-hospitalization,

inadequate muscle strength (muscle weakness in BLE rated ) and impaired balance with high risk of re-injury during transfers and gait due to inadequate assistance in the home,

unable to return home safely due to significant/pronounced impairment in the patient's ability to perform bed mobility, transfers and gait,

patient is no longer appropriate to return to previous home (private home) and family is actively looking for an assisted living with 24 hour care assist,

Patient is showing functional progress with skilled physical therapy comparing the clinical data from the _____ to the current clinical findings as evidenced by the following: muscle strength on both LE improved from /5 to /5, static standing balance improved from __ to __ , dynamic standing balance improved from __ to __ , supine <> sit at the edge of the bed improved from __ to __, bed rolling side-to-side improved from ___ physical assist to ___ physical assist, sit< >stand improved from ___ physical assist to ___physical assist, bed< >chair transfers improved from ___ physical assist to ___physical assist, gait with ___ improved from ___ physical assist to ___physical assist, stair training improved from ___ physical assist to ___physical assist. Patient needs further skilled physical therapy interventions to improve level of function, attain the established physical therapy long term goals and in order to return home safely.
The provision of skilled physical therapy treatment has improved the following areas: standing balance for static and dynamic to ----, muscle strength BLE to --/5, Tinetti balance and gait score of ---/28 resulted in improvement in bed mobility with supine <-> sit at the edge of the bed to ----- , transfers for chair <-> bed to moderate <> assist, sit <-> stand to assist and gait with rolling walker to physical assist <> assist.
The provision of skilled physical therapy treatment has improved the following areas: standing balance to for static and dynamic, muscle strength BLE to /5 resulted in improvement in bed mobility and transfers to assist.
Provided progressive therapeutic exercises, therapeutic activities, skilled gait training, neuromuscular reeducation to improve bed mobility, transfers, and gait.
The patient requires further skilled therapy due to unstable gait, unstable balance, muscle weakness to attain long term goals.
Patient was educated with progressive activity to improve bed mobility, transfers, and gait.
Continued patient training required in skilled progressive activity to improve function and safety in transfers and gait.
Treatment plan approach to include progression in static and dynamic balance, progressive muscular strengthening, transfers, and gait.

Assessment:

Muscle strength B LE: 3+/5 Bed mobility: supervision Endurance: Fair Transfer: Contact Guard Assist Balance Sit: Good Balance: Stand: G- Stairs: Moderate Assist Pain legs/ft: 5-6/10

NOTE: PROGRESS NOTE/UPOC: Established goals are still achievable and maximum improvement is yet to be achieved and the remaining functional deficits are still remarkable and can only be provided in skilled nursing facility due to ___________________. COMMUNICATION: Coordination of care was made with social worker about the date of discharge, OT ()

D/C

Patient has improved significantly in bed mobility, transfers, and gait but requires physical therapy in home setting to address actual environmental barriers, and actuate the functional skills gained in a subacute facility.
HOME EXERCISE PROGRAM: Patient was educated with quad sets, short arc quads, gluteal sets, straight leg raise, hip and knee flexion-extension, hip abduction to neutral, ankle pumps x 10 reps x 2 sets three times a day and demonstrated 100% understanding with return demonstration.
HOME EXERCISE PROGRAM: Patient was taught with leg exercises (quad sets, ham sets, ankle slides, gluteal sets, lying knee extension, straight leg raises, ankle pumps, sitting knee extension, sitting knee flexion, heel raises, standing knee flexion, standing knee raises, toe raises, standing hip abduction/adduction, mini squats x 15 reps x 2 sets and demonstrated 100% understanding with return demonstration.
Provided skilled physical therapy services with a level of complexity and sophistication that require the judgment, knowledge, and skills of a qualified physical therapist: Therapeutic Exercises for the purpose of restoring functional loss through progressive muscular strengthening, complex-progressive exercises, exercises to promote joint motion, mobility exercises; Therapeutic Activities which involve the use of functional activities (e.g., transfers, bending, lifting, carrying, reaching, catching) to restore functional performance in a progressive manner and directed at a loss or restriction of mobility, muscular strength, balance, or coordination requiring the skills of the therapist to design the activities, to address a specific functional need of the patient and to instruct the patient in performance of these activities; Manual Therapy with the provision of skilled manual techniques to effect changes in the soft tissues, articular structures, neural or vascular systems. Gait evaluation and training to improve ambulation directly performed as part of a one-on-one training program. Neuromuscular reeducation for the purpose of restoring balance, coordination, kinesthetic sense, posture, and proprioception (e.g., proprioceptive neuromuscular facilitation (PNF), Feldenkreis, Bobath, BAP’s boards, and desensitization techniques).

JUSTIFICATION FOR DISCHARGE: In the Medicare Benefit Policy Manual Chapter 8 Coverage of Extended Care (SNF) Services Under Hospital Insurance 30.2.2- Principles for Determining Whether a Service is Skilled, the deciding factor is not the patient's potential for recovery , but whether the services needed require the skills of a therapist or whether they can be provided by non-skilled personnel. In this case, the patient has reached a plateau functionally, and the exercises can be safely carried out by a caregiver. Although the patient has not reached the prior level of function, the patient's deterioration in mental status limits further progression in therapy. Patient would be requiring _____assist due to the risk of falling which can be safely provided by a non-medical person and that exercises to maintain the patient's function can be safely and effectively carried out by a caregiver.

Miscellaneous

the sevices cannot be carried by unskilled personel reasonable and necessary to the treatment of the patient's illness or injury

potential that the condition of the patient will improve materially in a reasonable and generally predictable period of time. Improvement is evidenced by objective successive measurements. potential that the condition of the patient will improve materially in a reasonable and generally predictable period of time. Improvement is evidenced

Patient does not suffer a transient or easily reversible loss of function which could reasonably be expected to improve spontaneously as the patient gradually resumes normal activities. The patient requires specialized skills, knowledge, and judgment of a physical therapist due to the complexity of the services provided to the patient requiring frequent treatment progressions and intervention adjustments designed to address the patient’s physical impairment with bed mobility transfers and gait in order to decrease risk of falling and re-injury.

development, course and outcomes of the skilled observations, assessments, treatment and training performed

However, if the criteria in §40.2.1(d)(3) are met, where there is clear documentation that, because of special medical complications (e.g., susceptible to pathological bone fractures),

inherently complex that it can be safely and effectively performed

, the physical therapist should regularly reevaluate the patient’s condition and adjust any exercise program

30.4.1 – (Rev. 1, 10-01-03) A3-3132.3A, SNF-214.3.A 30.4.1.1 Direct Skilled Therapy Services to Patients-Skilled Physical Therapy - General, Example 1, An 80-year old, previously ambulatory, post-surgical patient has been bed-bound for 1 week, and, as a result, had developed muscle atrophy, orthostatic hypotension, joint stiffness and lower extremity edema. To the extent that the patient requires a brief period of daily skilled physical therapy to restore lost functions, those services are reasonable and necessary and must be documented in the medical record (see §30.2.2.1).

RECERT

JUSTIFICATION FOR RECERTIFICATION: Patient current status is _____ in transfers and _____ in gait, however patient has reasonable potential to improve in transfers and gait to ______modified independent with further skilled training. Although further daily skilled therapy is available on an outpatient therapy or home health care basis, but the patient is at high risk for further injury from falling (as supported by standardized test, Tinetti Balance and Gait Assessment with a total score of ___ which is tantamount to high risk of falling) because of insufficient supervision and assistance could not be arranged for the patient to be home. Therefore, the physical therapy services as a practical matter can be provided effectively only in the inpatient setting (SNF) as specified under 30.7 - Services Provided on an Inpatient Basis as a “Practical Matter” of the Medicare Benefit Policy Manual, Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance.

JUSTIFICATION FOR RECERTIFICATION: Patient current status is _____ in transfers and _____ in gait, however patient has reasonable potential to improve in transfers and gait to ______modified independent with further skilled training. In spite of the fact that further daily skilled therapy is offered on an outpatient therapy or home health care basis, but based on the objective clinical evidence that the patient is at high risk for further injury from falling (as supported by the standardized test, Tinetti Balance and Gait Assessment with a total score of ___ which is tantamount to high risk of falling) because of insufficient supervision and assistance could not be arranged for the patient to be home. Consequently, the physical therapy services as a practical matter can be furnished effectively only in the inpatient setting (SNF) pursuant to the Medicare Benefit Policy Manual, Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance, 30.7 - Services Provided on an Inpatient Basis as a “Practical Matter”.

JUSTIFICATION FOR RECERTIFICATION: Patient current status is _____ in transfers and _____ in gait, however patient has reasonable potential to improve in transfers and gait to ______modified independent with further skilled training. Regardless of the fact that further daily skilled therapy may be obtained on an outpatient therapy or home health care basis, but the patient is at high risk for further injury from falling (as supported by the standardized test, Tinetti Balance and Gait Assessment with a total score of ___ which is tantamount to high risk of falling) because of insufficient supervision and assistance could not be arranged for the patient to be home. Hence, the physical therapy services as a practical matter can be rendered effectively only in the inpatient setting (SNF) based upon the patient’s unique condition and individual needs in accordance with the Medicare Benefit Policy Manual, Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance, 30.7 - Services Provided on an Inpatient Basis as a “Practical Matter”.

STROKE: Patient is beginning to demonstrate voluntary return of motor control post stroke due to skilled therapy and starting to reacquire the ability to carry out bed mobility, transfers, and gait which is a good indicator in returning to independence. Patient is still in the golden period of stroke recovery (rapid functional improvement: first 3 months as per Journal of Neurology, Neurosurgery, and Psychiatry). Physical therapy to continue in order for the patient to relearn skills that are lost post stroke. Evidence from clinical trials supports the premise that early initiation of therapy favorably influences recovery from stroke. According to Motor Recovery In Stroke by Bruno-Petrina et al, when the initiation of therapy is delayed, patients may in the interim develop avoidable secondary complications. In addition, many studies show that stroke rehabilitation can improve functional ability even in patients who are elderly or medically ill and who have severe neurologic and functional deficits.

FRACTURE: The skilled services of a therapist would be necessary to actually carry out the services due to _____, where there is an unhealed, unstable fracture which requires skilled therapeutic exercises and activities to improve function until the fracture heals and the skills of a therapist is needed to ensure that the fractured extremity is maintained in proper position and alignment during exercises. In this case,since the skills of a therapist may be required to safely carry out the MP given this particular patient’s special medical complications, therapy services would be covered. Reference: CMS IOM Publication 100-02, Chapter 15, Section 220.2 D

EVAL ONLY: The patient requires custodial care which can be provided under nursing supervision. Patient will be discharged with Functional Maintenance Program to perform repetitive and non-skilled exercises in order to preserve or maintain the patient's function to decrease risk of the development of contractures in bilateral LE and to decrease risk of pressure ulcers. According to Pub 100-02 of the Medicare Benefit Policy Manual, Application of the Principles to Physical Therapy Services: "Unskilled individuals may provide range of motion exercises unrelated to the restoration of a specific loss of function often safely and effectively. Passive exercises to maintain range of motion in paralyzed extremities that can be carried out by unskilled persons do not constitute skilled physical therapy." GOAL: Restorative Nursing Department will perform ROM exercise in BLE to decrease risk of developing joint contractures and to decrease risk risk of developing pressure ulcer. REHAB POTENTIAL: Patient has good rehabilitation potential in preserving range of motion in BLE through Functional Maintenance Program

PREVENT/SLOW DETERIORATION 1: Physical therapy is required in order to prevent or slow deterioration and maintain a beneficiary at the maximum practicable level of function due to the presence of:

This is in reference to Jimmo v. Sebelius case and the Medicare regualtions at 42 CFR 409.32(c), the level of care criteria for SNF coverage specify that the “restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities.”

PREVENT/SLOW DETERIORATION 2: Skilled Physical therapy is needed in order to prevent or slow deterioration and maintain a beneficiary at the maximum practicable level of function due to the presence of:

In the previously-issued Jimmo v. Sebelius Settlement Agreement Fact Sheet, CMS stated that the skills of a therapist are necessary to maintain, prevent, or slow further deterioration of the patient’s functional status, and the services cannot be safely and effectively carried out by the beneficiary personally, or with the assistance of non-therapists, including unskilled caregivers.

PREVENT/SLOW DETERIORATION 3: Skilled physical therapy is required in order to prevent or slow deterioration and maintain a beneficiary at the maximum practicable level of function due to the presence of:

In the Jimmo v. Sebelius settlement agreement, Medicare clarified its longstanding policy that when skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration when the beneficiary’s maintenance care needs cannot be addressed safely and effectively through the use of nonskilled personnel.

The treatment provided was directly and specifically related to an active written treatment plan based upon the physical therapy evaluation as approved by the physician.

HEP

HOME EXERCISE PROGRAM: Patient was educated with quad sets, short arc quads, gluteal sets, straight leg raise, hip and knee flexion-extension, hip abduction to neutral, ankle pumps x 10 reps x 2 sets three times a day and demonstrated 100% understanding with return demonstration.

HOME EXERCISE PROGRAM: Patient was taught with leg exercises (quad sets, ham sets, ankle slides, gluteal sets, lying knee extension, straight leg raises, ankle pumps, sitting knee extension, sitting knee flexion, heel raises, standing knee flexion, standing knee raises, toe raises, standing hip abduction/adduction, mini squats x 15 reps x 2 sets and demonstrated 100% understanding with return demonstration.

HOME EXERCISE PROGRAM: Patient was educated with exercise to improve bed mobility, transfers, and gait. Copy of the home exercise program was furnished to the patient/caregiver and was explained and demonstrated with 100% understanding at the time of physical therapy discharge.

HOME EXERCISE PROGRAM: Patient was educated in recognizing potential complications such as blood clots, joint dislocation, and infection. Patient was taught with leg exercises (quad sets, ham sets, ankle slides, gluteal sets, lying knee extension, straight leg raises, ankle pumps, sitting knee extension, sitting knee flexion, standing hip extension, heel raises, standing knee flexion, standing knee raises, toe raises, standing hip abduction/adduction, mini squats x 15 reps x 2 sets each. Patient was also taught on the proper use of rolling walker and cane. Patient was taught on how to avoid dislocation and instructed NOT to stand, bend knees, and twist at the same time. Patient was also taught with safety instructions to avoid falls. A copy of the home exercise program was provided to the patient. Completed training with the patient and demonstrated 100% understanding.

HOME EXERCISE PROGRAM: Patient was instructed to perform the exercise regimen such as Ankle Pumps: move the foot up and down as if pushing down or letting up on a gas pedal in a car. Quad Sets: lie on the back with the legs straight and toes pointed toward the ceiling then tighten the thigh or upper leg muscles then hold for 5 seconds and then release. Short Arc Quads: place rolled towel or pillow under the knee then straighten the knee and leg then hold for 5 seconds and then release. Gluteal Sets: squeeze the buttocks together hold for 5 seconds and then release. Straight Leg Raise: lift the leg toward the ceiling while keeping the knee straight then bend the opposite knee. Hip and Knee Bending: bring the leg in toward the chest, bending the knee and hip. Hip Rotation: roll the leg in toward the other leg and then back out. Hip Outward and Inward: move the leg out to the side and then back, keeping the knee straight and toes pointed toward the ceiling. Knee Push: put a towel roll under the ankle and push the knee down into the bed. Patient was also instructed to perform the exercises 20 reps each 3x/day. The patient was given a copy and patient demonstrated 100% understanding during the session.

DME

WALKER: Patient needs two-wheeled/four-wheeled rolling walker due to mobility limitations (muscle weakness of the trunk and LE, standing balance deficit, impaired muscular coordination) that remarkably impair the patient's ability to participate with activities of daily living. The use of the walker will decrease the patient's risk of falling. Patient will be able to use walker safely WITH assist. Patient's functional mobility deficit will be adequately resolved with the use of walker.
CANE: Patient needs standard cane to decrease risk of falling due to mobility limitation that significantly impairs ability to participate ADL due to muscle weakness of the trunk and LE, standing balance deficit, and impaired muscular coordination.
WHEELCHAIR: Patient has mobility limitations due to standing balance deficit and muscle weakness in the LE that remarkably impair the patient's ability to perform basic and intstrumental activities of daily living. Patient's mobilty cannot be resolved by the use of a walker or cane. Patient's home provides sufficient access between rooms and maneuvering space and surface for the use of wheelchair. The use of wheelchair will significantly improve the patient's ability to participate ADLs. Patient has sufficient UE function and mental capabilities needed to self- propel the wheelchair OR caregiver is able and willing to provide assistance with the wheelchair.
HOSPITAL BED: Patient has the need to elevate the bed due to _____. Patient has a medical condition which requires positioning of the bet; not feasible with an ordinary bed, to alleviate the pain. Patient requires head of bed to be elevated due to :CHF, COPD, increase risk for aspiration issues. Pillows and wedges were tried but not sufficient. Patient requires the need for frequent body positioning changes.

Exercise

General

Therapeutic Exercises: open kinematic chain exercises on bilateral LE with focus on hip, knee, ankle motions in sitting and [[[[standing to promote controlled mobility during transfers and gait; concentric exercises with minimal manual resistance for hamstrings and quadriceps femoris, tibialis anterior and gastroc-soleus x 10 reps to improve muscular control during transfers and gait; progressive resistive exercises on bilateral lower extremities to improve muscular strength on all planes of motion x 15 reps x 1 set..
Balance training: standing balance training to improve balance and equilibrium during transfers and gait with balance within the base of support, balance outside of the base of support, marching in place, partial squat, modified forward lunges, lateral lunges, toe lifts, side leg raise, single leg stance.
Gait training (see functional assessment).
Performed bed mobility training (bed rolling left then right, lying to sit then sit to lying), sit to stand and bed<> wheelchair transfer) with focus on sequencing and safety techniques.
Performed negotiating uneven surface (carpeted floor), curb step, navigating stair with emphasis on sequencing and safety techniques.
self positioning and hand placements, approaching bed and chair, stands/sits/trunk lifts/turns, repositioning and gait with focus on LE propulsion, consistency and rhythmicity in steps
focus on providing a structure for motor learning paradigm which includes: massed/cont practice, blocked sequencing rather than random type of practice, parameter or environmental variance (preparatory activity then task oriented training), activity type, errorless learning rather than error learning, and immediate feedback.
utilized intrinsic feedback (patient's assessment of performance during a performance) and extrinsic feedback (provided by the therapist during or after a performance.
Provided eclectic feedback during the training with Knowledge of Performance (KP) and on the end of the performance with Knowledge of Results (KR) or terminal feedback.
Performed activities with a pre-determined sequence utilizing the least amount of cues (hand over hand, verbal, or tactile cues) that allow the patient to complete the sequences successfully with minimal to no error.
focus to facilitate neuroplasticity (through the principle that neurons that train together, rewire together), by practicing the specific task as part of the training as many times in this session to enhance the prospect of facilitate permanent changes through neuroplasticity.
performed meaningful tasks, task-oriented training, and motor learning principles of blocked practice, errorless learning, and simulate patient's environment.

Therapeutic exercises were performed to improve bed mobility, transfers, and gait: progressive resistive exercises on bilateral lower extremities on all planes of motions with red theraband x 15 reps, standing balance exercises to improve equilibrium; open kinematic chain exercises in standing with marching in place and anterior and lateral step to improve muscular coordination during gait, closed kinematic chain exercises with partial squat to improve hip-knee- ankle joint stability x 15 reps each exercise.
Performed bed mobility training (bed rolling left then right, lying to sit then sit to lying), sit to stand and bed<> wheelchair transfer) with focus on sequencing and safety techniques.
Performed negotiating uneven surface (carpeted floor), curb step, navigating stair with emphasis on sequencing and safety techniques.
Gait training (see functional assessment).

HIP REP

Therapeutic Exercises: supine short arc quads with 2 pounds weight, heel slides, ankle pumps, seated long arc quds (mod assist with ___ LE), marching in standing, heel/toe raises, hamstring curls, hip abduction<> neutral hip. NEURO-ED: Proprioceptive neuromuscular facilitation was performed with Contract-Relax-Antagonist-Contract x 10 where quadriceps isometrically contracted for 6 seconds, then the antagonist muscle immediately contracted for 6 seconds then the right knee joint pushed into its new range from extension to flexion.

KNEE REP: Performed the following actively within the available range gained today: left hip abduction and adduction, hip internal and external rotation, hamstring curl with the use of board, ankle pumps x 10 reps x 2 sets; short arc quads with bolster underneath x 10 reps x 2 sets with 3 pounds ankle weight (((left))) and ((( pounds ankle weight right))); quads isometrics x 6 seconds hold x 10 reps; progressive resistive exercises in supine position right LE and left ankle motions x 10 reps x 3 sets. Patient has pain in the knee 7-8/10 with movement. ROM measurement for the --- knee: from extension to flexion actively from negative 10 degrees extension to 92 degrees flexion taken in supine position after muscle stretching.
THERA EX:
forward reach to facilitate the patient's performance with sit < >stand;
multi-directional reaches to improve bed<> chair transfers;
lateral sways in standing to improve lateral stability during standing and to decrease of falling laterally;
partial squat to improve co-contraction of the hamstrings and quadriceps femoris to improve sit<> stand;
sitting push up with facilitation of the triceps brachii to improve sit< >stand;
facilitation of the vastus medialis oblique to improve control during terminal knee extension necessary for sit< >stand and bed<> chair transfers;
modified forward lunges to improve hip-knee-ankle stability to decrease risk of falling anteriorly
modified lateral lunges to improve lateral trunk and LE stability to decrease of falling;
Hip swivels exercise in standing where patient was instructed to visualize clock at feet then swivels hips in smooth cirlces "around the clock" for hip cirlcles to improve dynamic balance during turning and changing directions.

NU step to promote temporal conjunction of arm and contralateral leg at apex of shoulder and hip excursions during gait

NU step to improve gait with arm-leg-synchrony through contralateral movements of the arms and legs to promote coordinated gait.

Intrinsic standing balance exercises with narrow base of support, semi-tandem position, ankle dorsiflexion, hip abduction and extension.

Balance

Ankle Strategy

minimal-moderate antero-posterior weight shifts with hips and knees straight on level surface to promote ankle strategy to improve gait stability
minimal-moderate medio-lateral weight shifts with hips extended on level surface to promote ankle strategy to improve medilateral stability in standing
low speed, small perturbations of balance to promote ankle strategy to improve steady standing
low speed, minimal perturbations of balance in standing to promote ankle strategy to decrease risk of falling laterally
reaching medio-lateral directions in standing to promote ankle strategy to improve standing balance
reaching forward-backward directions in standing to promote ankle strategy to improve stability in antero-posterior directions
alternate step-ups onto a low level step without using handrail with 25% physical assist to promote ankle strategy to improve stair climbing
use a Biomechanical Ankle Platform System (BAPS) board with large dome.

Hip Strategy

moderate antero-posterior weight shifts on a variety of support surfaces to promote hip strategy and pelvic control in standing
standing balance on a narrow support surface (i.e., wedge) to promote hip strategy and pelvic stability in standing
moderate-speed hip perturbations to improve hip strategy in performing dynamic gait
reaching for objects at lower heights to improve hip strategy to promote standing balance
reaching superior<> inferior directions in static standing to improve hip strategy in order to improve dynamic gait
perform tandem standing to promote static control of the hip during standing
perform single-leg stance to improve hip strategy in order to promote pelvic stability in standing
tandem gait to improve hip strategy in order to improve dynamic control during gait

Stepping Strategy Training

standing balance on foam/wedge and reaching outside hand’s reach
lateral stepping over obstacles to activate stepping strategy to improve dynamic balance during gait
forward stepping over obstacles to facilitate stepping strategy to improve dynamic balance during gait
large, rapid balance perturbations with predictable and unpredictable to improve
Step-ups and step-downs to facilitate stepping strategy to improve dynamic balance during gait

Center of Gravity Control

sit on an unstable surface – wedge, mats, BAPS board, therapy ball to promote control of the center of gravity to improve balance
alter upper extremity support on the seating surface – one hand, no hands, etc. to promote control of the center of gravity to improve balance
incorporate reaching/throwing to challenge limits of stability to promote control of the center of gravity to improve balance
ankle alphabet in the air utilizing one leg with/without upper body support to promote control of the center of gravity to improve balance

Base of Support Training

standing feet together to improve proprioceptive response in changing base of support to improve dynamic gait
tandem standing together to improve proprioceptive response in changing base of support during gait
single limb together to improve proprioceptive response in changing base of support
training the proprioceptive system by disadvantaging the visual system with standing on noncompliant surfaces with eyes closed or vision distorted

Mobility Ex progressions

SIT TO STAND

Sit to stand functional training from different heights to promote sit to stand transfer.
Sit to stand functional training on chairs with varied heights to facilitate sit to stand transfer.
sitting push-ups to facilitate sit to stand transfer.
Partial squats to activate co-contraction of quadriceps and hamstrings to facilitate sit to stand transfer.
Forward reached with clasped hands to assist in sit to stand transfer.
Forward reaching with rolling back and forth to promote sit to stand transfer.

STANDING UNSUPPORTED

Resisted lateral steps to facilitate lateral stability in standing
Standing on foam to facilitate balance reaction during standing
Semi-tandem to promote equilibrium during standing
Lateral sways to improve lateral control and stability
Narrow base-head and trunk turns to improve turning and changing directions
Narrow base- arm reaches to promote standing balance

SITTING UNSUPPORTED

Pelvic tilt progression sitting to improve trunk control in sitting.
Partial sit-ups to facilitate sitting.
Sitting PNF diagonals to assist sitting unsupported.
Pointing at targets using the head to promote sitting balance unsupported.

STANDING TO SITTING

Wall slides to promote standing to sitting.
Partial squats with exercise bands to facilitate standing to sitting.
Standing forward hip thrusts to assist standing to sitting.

TRANSFERS

Segmental turns to facilitate transfers.
Simultaneous hip-knee flexion to facilitate iliopsoas and hamstring to improve transfers.
One-legged standing to promote balance in transfers.
Head turns through the movement pattern to facilitate transfers.
Reaches through the movement pattern training to facilitate bed< >chair transfers.
Side steps training to improve safety transfers.

STANDING WITH EYES CLOSED

Head turns with eyes closed to facilitate balance reaction in standing
Turns with eyes closed to develop proprioception during standing balance
Sit to stand with eyes closed to promote standing balance
Ankle rocks with eyes closed to promote ankle strategy in standing
Lateral sway with eyes closed to improve proprioception in standing balance

STANDING WITH FEET TOGETHER

Hip abduction to facilitate standing balance
Balance board to facilitate ankle strategy and dynamic standing balance
Lateral stepping to promote standing balance
Lateral reaching to facilitate dynamic standing balance
Lateral sways to promote standing balance
Multidirectional dot reaches to promote dynamic standing balance

FORWARD REACH

Plantarflexion with resistance progression to develop forward reach to promote standing balance
Trunk extension to promote trunk control during standing balance
Ankle sways with forward reach to promote standing balance
Wobble board with forward reach to promote standing balance
Plantarflexion stretch to develop forward reach to promote standing balance

RETRIEVING OBJECT FROM THE FLOOR

Knee squats to promote standing balance in order to facilitate retrieving object from the floor balance.
Progressive reach to facilitate standing balance in order to retrieve object from the floor
Wall slides to promote hip-knee-ankle control to facilitate retrieving object from the floor.
Knee flexion to while sustaining standing balance to facilitate retrieving object from the floor
Hip flexion to promote standing balance to facilitate retrieving object from the floor.
Weighted partial squats while maintaining standing balance to facilitate retrieving object from the floor

TURNING TO LOOK BEHIND

Axial rotation to facilitate turning to look behind to develop dynamic standing balance.
Trunk rotation to facilitate turning to look behind to develop dynamic standing balance.
PNF rhythmic stabilization to facilitate turning to look behind to develop dynamic standing balance.
Axial mobility work to facilitate turning to look behind to develop dynamic standing balance.
Knee rocks to facilitate turning to look behind to develop dynamic standing balance.
Looking behind at targets sitting progression to standing to facilitate turning to look behind to develop dynamic standing balance.
Trunk turns to facilitate turning to look behind to develop dynamic standing balance.

TURNING 360 DEGREES

Vestibular exercise to assist turning 360 degrees to promote standing balance.
Head turns to assist turning 360 degrees to promote standing balance.
One-legged stand to assist turning 360 degrees to promote standing balance.
Progressive head turns sitting progressing to standing to assist turning 360 degrees to promote standing balance.
Progressive trunk turns sitting progressing to standing to assist turning 360 degrees to promote standing balance.

PLACING ALTERNATING FEET ON STOOL

facilitate dynamic standing balance with marching to aid in placing alternating feet on stool to balance.
Progressive marching using exercise band at weak part for resistance to aid in placing alternating feet on stool to facilitate dynamic standing balance.
Cone taps to improve in placing alternating feet on stool to facilitate dynamic standing balance.
Long arc quads to improve in placing alternating feet on stool to facilitate dynamic standing balance.
Hip abduction to improve in placing alternating feet on stool to facilitate dynamic standing balance.
One-legged stands to improve in placing alternating feet on stool to facilitate dynamic standing balance.

TANDEM STANDING

Side stepping to assist tandem standing to develop standing balance.
Semi-tandem progression to assist tandem standing to develop standing balance.
Narrow base dot reach to assist tandem standing to develop standing balance.
One-legged standing to assist tandem standing to develop standing balance.
Tandem walking to assist tandem standing to develop standing balance.
Narrow base progression with a throw to assist tandem standing to develop standing balance.

ONE-LEGGED STANDING

Narrow base progression with ball kick to aid one-legged standing to facilitate dynamic standing balance.
Leg swing to aid one-legged standing to facilitate dynamic standing balance.
One-legged standing to aid one-legged standing to facilitate dynamic standing balance.
One legged standing on exercise pads, touching toe to other pads to aid one-legged standing to facilitate dynamic standing balance.
Tandem and one-legged ball throw to aid one-legged standing to facilitate dynamic standing balance.
One-legged standing with eyes closed to aid one-legged standing to facilitate dynamic standing balance.

STANDING BALANCE EXERCISES

Standing side lean to promote standing balance.
Front lean to promote standing balance.
Toes up to promote standing balance.
Heel cord stretch to promote standing balance.
One-legged stand to promote standing balance.
One-legged stand with eyes closed to promote standing balance.
Heel stand to promote standing balance.
Toe stand to promote standing balance.
Head tilt to promote standing balance.
Head tilt up and down to promote standing balance.
Two legged standing rotation to promote standing balance.
Head motion to promote standing balance.
Eye motion to promote standing balance.
Grapevine to promote dynamic standing balance.
High stepping to promote standing balance.
Walking head turn to promote standing balance.
Walking figure eight to promote dynamic standing balance.
Semi tandem standing to promote dynamic standing balance.
Tandem standing to promote standing balance.
Circle turn to promote dynamic standing balance.
Resisted walking to promote dynamic standing balance.
Pelvic rotation to promote dynamic standing balance.

ABDOMINAL STRENGTHENING

Single leg slide to promote trunk control and stability.
Alternating lower extremity motion (modified bicycle) to promote core stabilization.
Curls ups to promote trunk control and stability during supine to sit
Curls downs to promote trunk control and stability when performing sit to supine
Diagonal curl ups to promote trunk control and stability to improve side lying
Double knee-to-chest to promote trunk control and stability
Supine hip hike to promote trunk control and stability to improve bed mobility.
Single leg bridging to promote trunk control and stability.

Neuromuscular

Performed compound isotonic exercises which involve movement at multiple joints in the lower extremities requiring contractions of the agonist muscles for increase recruitment of motor units and recruit synergist muscles to assist the movement in order to improve bed mobility and transfers.
Closed Kinematic Chain exercise to improve joint proprioception, thereby increasing dynamic stability of the joint; to facilitate muscular cocontraction which provides dynamic stabilization and activate type I and II mechanoreceptors helping to reduce pain or inhibit pain, provide continues feed back about where the body is in space
To activate mechanoreceptors in the joints along with the muscle spindles of the foot muscles to improve positive support reflexes and a variety of automatic reflexive reactions.
Weightbearing exercises to activate the mechanoreceptors in the joints and muscles, evoking reflexive activity in the extensors and inhibition of the flexor muscles.

PNF

Neuromuscular reeducation with proprioceptive neuromuscular facilitation through bilateral asymmetrical approach lower extremity pattern with key to the lower trunk pattern to improve transfers and gait.

Performed neuromuscular reeducation with recuperative motion with the use of combination of movements to reduce or circumvent muscle weakness to develop muscle strength necessary to improve transfers and gait performance.

Performed neuromuscular reeducation with multi-faceted technique with the use of slow-reversal (reversal of antagonistic muscles), rhythmical concentric contraction of agonist and antagonist without relaxation of muscles to facilitate in positioning limb during bed mobility and transfers.

Progressed neuromuscular reeducation with the use of slow-reversal- hold (SRH) with isometric contraction gradually applied at the end of range of movement to facilitate mobility which needs pelvic lifting, boost, to move from supine to side.

Neuromuscular reeducation performed with muscular contractions with emphasis given to one side of the joint to improve motion, preceded with an isotonic contraction on the stronger component with the use of quick stretch at lengthened range with strong verbal command, then employ isometric contraction at the shortened range to enhance the gamma bias to improve range of motion necessary for bed mobility.

Neuromuscular reeducation with intensity progression during isometric contraction followed by isotonic contraction throughout and quick stretch at the point of weakness and isometric contraction at the end of the range of movement to facilitate lower extremity movement during bed mobility and transfers.

Progression of neuromuscular reeducation with "timing for emphasis" of movement to improve muscular strength on a specific component of the movement pattern with the application of manual isometrics to the point of optimal contraction to facilitate movement necessary during bed mobility and transfers.

Progressed therapeutic activities with the use of muscular agonistic reversal which promotes concentric and eccentric contractions of flexor and extensor component of one pattern at a time to facilitate grooming activities.

Therapeutic procedures performed and upgraded with the use of tendinous pressure and prolonged stretch to decrease muscle spasticity to allow more movements for the performance of bed mobility and activities of daily living. Therapeutic massage was also done and heating application to help inhibit spasticity and prior to muscular stretching to gain more range of motion necessary for dressing and undressing, and etc.

neuromuscular reeducation with prolonged tendinous pressure to decrease muscle spasticity to allow more movements for the performance of bed mobility.

neuromuscular reeducation performed with the use of isotonic movement with resistance at the end of concentric range and then followed by controlled rhythmical sequence of eccentric- concentric contractions of the muscles to promote bed mobility.

Performed neuromuscular reeducation with the use of rhythmic stab to increase range of motion by decreasing muscle splinting around the joint and to decrease pain resulting in limitation of motion, thereby decreasing physical assistance during bed mobility and transfers.

Performed neuromuscular reeducation progression to decrease the limitation of motion with the use of available isotonic contraction on the rotatory component and isometric contraction for the rest of the component into the shortened range to improve transfers.

Neuromuscular reeducation with focus in developing movement stability to improve co-contractions or simultaneous contractions of muscles around the joint to improve bed mobility activities.

neuromuscular reeducation performed with the use of rhythmical rotation to inhibit spasticity performed around the longitudinal axis of the joint/extremities to improve performance in bed mobility, transfers, and gait.

Coordination

movement composition training ( heel to knee to toe technique, foot pointing, and gait) to promote the patient's ability to control movement with several muscle groups acting together with focus on quality of movement, control, speed, and reaction time in order to improve performance transfers and gait.

movement accuracy training to improve the patient's ability to gauge distance and speed of voluntary movement with focus on quality of movement, control, speed, and reaction time in order to facilitate effective transfers and gait.

LE joint stabilization/fixation/postural holding training to improve the patient's ability to hold stationary posture to improve elevating, pushing, and lowering the body necessary for sit<> stand and bed< >chair transfers.

reciprocal movement coordination training to improve the patient's ability to reverse movement (agonist <> antagonist) with emphasis in the quality of movement, control, speed, and reaction time to improve reciprocal gait.

proprioceptive training to improve joint position sense by moving the patient's extremity through a predetermined range of motion to improve patient's equilibrium necessary for transfers and gait.

Kinesthetic training to improve the patient's body awareness during transfers and gait while in motion and to improve perception of body movement to decrease risk of falling.

Neural

Skilled interventions provided include teaching, instruction, demonstration, and training incorporating with the use of kinesthetic sense by activating neural receptors in the muscles and joints with the use of sensory reception approach.

Skilled interventions provided include education, instruction, demonstration, and training as it relates to joint protection principles with the use of techniques to protect the joints in performing the activity.

Skilled interventions provided include education, instruction, demonstration, and training as it relates to biomechanical alignment, which involves body alignment position in weight-bearing and non weight-bearing situations.

Skilled interventions provided include education, instruction, demonstration, and training incorporating proprioceptive approaches with the use of sensations from joints, muscles, and connective tissues that lead to body awareness.

Skilled interventions provided include education, instruction, demonstration, and training incorporating perceptual motor integration approaches such as visual-motor integration and adaptation.

Skilled interventions provided include education, instruction, demonstration, and training incorporating osteokinematic alignments with the use of movements occurring between two segments (bones) relative to the three cardinal planes.

Skilled interventions provided include education, instruction, demonstration, and training as it relates to incorporating neuromuscular treatment approach with the use of treatment approaches.

Skilled interventions provided include education, instruction, demonstration, and training incorporating stereognosis with the faculty of perceiving and understanding the form and nature of objects by the sense of touch.

Skilled interventions provided include education, instruction, demonstration, and training incorporating barognosis with the perception of weight by cutaneous and muscle sense.

Skilled interventions provided include education, instruction, demonstration, and training integrating sense approach with the recognition and awareness of the location of external cutaneous stimulus.

Skilled interventions provided include education, instruction, demonstration, and training as integrating with the use of kinesthetic sense by activating neural receptors in the muscles and joints with the use of sensory reception approach.

Skilled interventions provided include education, instruction, demonstration, and training with the use of proprioceptive sense with the sensory input and feedback of joint position.

Skilled interventions provided include education, instruction, demonstration, and training integrating with the use of osteokinematics with the relationship of the bone and its associated joint movements.

Skilled interventions provided include education, instruction, demonstration, and training as it relates to arthrokinematics, with the adjoining joint surfaces move each other during osteokinematic joint movement.

Skilled interventions provided include education, instruction, demonstration, and training as it relates to with the use of adaptation phenomena providing perceptual plasticity and mechanism of visual coding.

Skilled interventions provided include education, instruction, demonstration, and training as it relates to with the use combined cortical integrative approach utilizing visual and verbal feedback.

StandardTests

Tinetti Performance Oriented Mobility Assessment Total Score for Balance and Gait: ___/28 (Balance: /16 and Gait /12). Risks Indicators: equal or less than 18 is HIGH RISK for fall, 19-23 is MODERATE RISK for fall, equal or greater than 24 is LOW RISK for fall.

Tinetti Balance and Gait test was performed to objectively measure balance and gait deficits for significant changes, position changes, and gait maneuvers used during mobility in order to assess patient’s ability to perform specific gait and balance tasks and as predictive measure for falls. .Areas Tested: BALANCE: sitting balance, rises from chair, attempts to rise, immediate standing balance (first 5 seconds), standing balance, nudged, eyes closed, turning 360 degrees, and sitting down; GAIT: initiation of gait, step length and height, foot clearance, step symmetry, step continuity, gait path, trunk sway, and walking time.

Timed Up & Go Test (TUG) Score: ___

Gait Interpretation: Older adults who take longer than 13.5 seconds to complete the TUG have a high risk for falls (Shumway-Cook Measurement) Transfer Interpretation: According to Podsiadlo and Richardson, 1991 Timed Up & Go Test Score less than 20 seconds for Functional Mobility Skill (Community-Dwelling Elderly People with a variety of medical conditions) is indicative of independent for basic transfers. Procedure: The timed “Up and Go” test measures the time taken by the patient to stand up from a standard arm chair, walk a distance of 3 meters (118 inches, approximately 10 feet), turn, walk back to the chair, and sit down. Patient started with back against the chair, arms resting on the armrests, and walking aid at hand. Patient was instructed that, on the word “go” to get up and walk at a comfortable and safe pace to a line on the floor 3 meters away, turn, return to the chair and sit down again.

Berg Balance Scale Score:___/56. Interpretation: 41-56 = low fall risk, 21-40 = medium fall risk, 0 –20 = high fall risk .Areas Tested: sitting to standing, standing unsupported, sitting unsupported, standing to sitting, transfers, standing with eyes closed, standing with feet together, reaching forward with outstretched arm, retrieving object from floor, turning to look behind, turning 360 degrees, placing alternate foot on stool, standing with one foot in front, standing on one foot.

Performed Gait Speed Test to establish data on gait velocity and to provide objective measures to forecast the patient's risk of falling and to assist in safe discharge planning of the patient with the goal of minimized re-hospitalizations/re-injury. Patient has a score of _____ feet/sec and is determined to be ____ of falling; normative value: equal to 1.86 feet/sec or higher.

Dynamic Gait Index Total Score: ___/24. Interpretation: less than 19/24 = predictive of falls in the elderly; greater than 22/24 = safe ambulators. The following are the eight facets of gait scored individually: I. Gait level surface:(); II Change in gait speed (); III. Gait with horizontal head turns(); IV. Gait with vertical head turns(); V. Gait and pivot turn(); VI. Step over obstacle(); VII. Step around obstacles();VIII.Steps ()

SITTING FUNCTIONAL REACH TEST: Modified sitting functional reach test was performed to objectively measure risk for falling in sitting forward and laterally with the following results: Forward reach was at 8 inches and lateral reach to the right at 4 inches and to the left at 4 inches which indicated high risk for falling; standardized value indicates that for ages >65 y/o would be at high risk for values less than 13 inches for forward reach and 8 inches for lateral reach.
- GOAL: SITTING FUNCTIONAL REACH TEST: Patient will exhibit forward reach in sitting to at least 13 inches and lateral reach to at least 8 inches to decrease risk of falling and to improve mobility and transfers. e.g., CURRENT: SITTING FUNCTIONAL REACH TEST: Patient exhibit progress with forward reach in sitting to 8 inches (normal value: at least 13 inches) and lateral reach to 4 inches for both sides (normal value: at least 8 inches)

Five Times Sit to Stand Test

Performed Five Times Sit to Stand Test to assess functional lower-limb muscle strength, functional change of transitional movements, balance performance, and assess fall risk. Patient Instruction: "I want you to stand up and sit down 5 times as quickly as you can when I say 'Go'." SCORE: Patient's score was ________ seconds and determined to be _____ risk of falling. Interpretation: The normative data by Bohannon et al, 2006 for ages , the cut off indicates below or lower times = better scores) 60-69 y/o = 11.4 sec 70-79 y/o = 12.6 sec 80-89 y/o = 14.8 sec

Cardiac

VS prior to treatment= BP: mmHg, PR: bpm, RR: cpm, SpO2: % room air, RPE: /10, Dyspnea Scale: 0/4
VS immediately after gait = BP: mmHg, PR: bpm, RR: cpm, SpO2: % room air, RPE: /10, Dyspnea Scale: /4
Recovery VS after 5 mins= BP: mmHg, PR: bpm, RR: cpm, SpO2: % room air, RPE: /10, Dyspnea Scale: 0/4

New York Heart Association Functional Classification:
PRECAUTION iHEART Program: NYHA Class III-A (2-3 METS)
Karvonen's/Target Heart Rate= bpm
Minimum Training Heart Rate: 220 - (Age) = (Max HR) - 70bpm (Rest. HR) = x .60% (Min. Intensity) = + (Rest. HR) = bpm
Maximum Training Heart Rate: 220 - (Age) = (Max HR) - 70bpm (Rest. HR) = x .70% (Max. Intensity)= + (Rest. HR) = bpm

GOAL: Patient will exhibit decrease physical activity restriction as evidenced by improvement in the New York Heart Association Functional Classification rating from ____ (METS) to ____ (METS) in order to improve ability to carry on physical activity for transfers and gait without palpitation, dyspnea with exertion or anginal pain.
GOAL: Patient will demonstrate progress in the New York Heart Association Functional Classification rating from Class __ (METS) to Class __ (METS) to allow for safe mobility and gait without signs and symptoms of cardiac distress during gait.
GOAL:Patient will progress in the New York Heart Association Functional Classification rating from Class __ (METS) to Class __ (METS) as an effective strategy in assessing safe activity levels in order to progress physical therapy interventions without signs and symptoms of cardiac distress during functional transfers and gait.

CLINICAL IMPRESSION: Patient has a score of /10 in the Modified Borg Scale Rating of Perceived Exertion (RPE) during functional testing with marked limitation of physical activity and less than ordinary activity causes dyspnea with exertion and therefore assessed to be Class ____ in the New York Heart Association Functional Classification rating. Patient will be under iHEART Program to closely monitor cardiac response with progressive skilled therapy to safely progress the physical therapy interventions and skilled training in order to improve functional transfers and dynamic gait.
CLINICAL IMPRESSION: Cardiac Assessment revealed a score of /10 in the Modified Borg Scale Rating of Perceived Exertion (RPE) during clinical testing with substantial limitation of physical activity and less than ordinary activity causes shortness of breath with exertion and therefore assessed to be Class ____ in the New York Heart Association Functional Classification rating. Patient will be placed under iHEART Program to closely monitor cardiac response with progressive rehabilitation to safely progress the physical therapy treatment and skilled training in order to improve functional transfers and dynamic gait.

NECESSITY: Without skilled physical therapy services, patient will be unable to overcome recent cardiac medical problem and increase burden of care for transfers and gait, experience fluctuating levels of performance during transfers, increasing risk of falls when attempting to perform ADLs. Skilled physical therapy is medically reasonable and necessary to ensure adequate respiratory ventilation
NECESSITY: Without the provision of skilled physical therapy services, patient will be at risk for further functional deterioration and at risk for cardiac/respiratory distress during mobility performance, therefore only skilled physical therapy can safely progress with careful monitoring of vital signs to decrease risk of medical complications and to ensure medical safety.

- Patient has _____ but not the primary reason for hospital admission. Patient will not be under iHeart Program but requires monitoring of cardiac signs and symptoms and therefore will be under cardiac precaution to ensure safety during skilled physical therapy.

PRECAUTION: iHEART-P
Patient will be put under iHEART-P to closely monitor respiratory response of the patient with physical therapy interventions in order to prescribe and implement safe progressions therapeutic exercises and activities.
GOAL: with > 92% oxygen saturation rate consistently and no respiratory distress or shortness of breath with exertion during gait.
VS prior to treatment= BP: mmHg, PR: bpm, RR: cpm, SpO2: % room air, RPE: /10, Dyspnea Scale:
VS immediately after gait = BP: mmHg, PR: bpm, RR: cpm, SpO2: % room air, RPE: /10, Dyspnea Scale:
Recovery VS after 5 mins= BP: mmHg, PR: bpm, RR: cpm, SpO2: % room air, RPE: /10, Dyspnea Scale:

Modified Borg Scale Rating of Perceived Exertion (RPE) Score: ----/10 RPE Interpretation:0= Nothing at all; 0.5= Very, very light (very, very slight SOB); 1= Very light (very mild SOB); 2= light (mild SOB); 3= Moderate (moderate SOB); 4= Somewhat hard; 5=Hard (strong or hard breathing); 6=-; 7= Very hard (Severe SOB or very hard breathing); 8=-;9= Very, Very Hard (Extremely severe); 10 =Maximal (Shortness of breath so severe you need to stop)

IE

Skilled Physical Therapy evaluation, examination, and assessment were completed. Plan of care and goals were developed and skilled treatment recommended for therapeutic exercises, neuromuscular reeducation, therapeutic activities, gait training to effect significant changes in the patient's functional performance. Tinetti test for balance and gait conducted with a total score of_____/28 indicating high risk of falling. Patient was educated with safety techniques in bed mobility, use of call light.

Performed manual resistive exercises with facilitation of bilateral iliopsoas and gluteus maximus, hip abductors (gluteals and tensor fascia latae) and hip adductors (magnus, longus, brevis, and minimus), quadriceps and hamstring, tibialis anterior and gastroc-soleus; static and dynamic standing balance exercises to improve transfers; open kinematic chain exercises to improve movement coordination for transfers and gait.

Gait assessment and training with the use of walker which required maximal/moderate physical assist x 20 feet. Patient was initially instructed with safety use of walker including gait pattern.

Therapeutic Activities: initiated bed mobility training, transfer training, and skilled physical assessment: bed mobility required ___physical assist; transfers with sit< >stand and bed<> chair required ___ physical assist; standing balance rated fair minus for static and poor plus for dynamic, muscle strength with manual muscle testing rated 3+/5 for both lower extremities,

Pain in ____ rated /10 which occurs at least daily, it is not easily relieved, and affects the patient’s sleep, physical energy, concentration, and ability/ desire to perform physical activity. STANDARDIZED TEST:

Patient actively participated with the physical therapy evaluation and treatment.

HPP Plus

CURRENT REFERRAL : Patient was admitted in the hospital and received acute medical care due to___. Patient was referred to sub-acute rehabilitation due to substantial decline in bed mobility, transfers and gait due to the medically complex conditions. Clinical objective problems include: gait deficit, muscle weakness affecting mobility, equilibrium or balance deficit, pain interfering with movements, tenderness, muscle spasm, muscle guarding, high risk of falling. These clinical problems have resulted in significant functional deterioration, as evidenced by a remarkable deficit in sit <-> stand and bed <-> chair transfer, bed mobility, gait on level surface, [[[navigating stairs]]]] requiring skilled physical rehabilitation.

marked deficit in moving around in bed with scooting, bridging, bed rolling side to side and moving from lying to sitting and sitting to lying; sit to stand and bed< > chair transfers; ambulate on level surface and negotiating steps]]]
PRECAUTION: Time Preference: Projected D/C Date: D/C location: DME: FI:

STANDARDIZED TESTS:

Tinetti Performance Oriented Mobility Assessment Total Score for Balance and Gait: ___/28 (Balance: /16 and Gait /12). Risks Indicators: equal or less than 18 is HIGH RISK for fall, 19-23 is MODERATE RISK for fall, equal or greater than 24 is LOW RISK for fall.

Elderly Mobility Scale Score:___/20 Scores under 10 – generally these patients are dependent in mobility manoeuvres; require help with basic ADL, such as transfers, toileting and dressing. Scores between 10 – 13 – generally these patients are borderline in terms of safe mobility and independence in ADL i.e. they require some help with some mobility manoeuvres. Scores 14 and over – generally these patients are able to perform mobility manoeuvres alone and safely and are independent in basic ADL.

CLINICAL IMPRESSIONS: Patient recently deteriorated in bed mobility, functional transfers and gait as evidenced by the previous/prior level of function as opposed to/against the current level of function due to the medically complex conditions. Patient requires skilled physical therapy interventions on a daily basis and can be provided, as a practical matter, only on an inpatient basis in a SNF in lieu to the patient's inability to return home safely with Elderly Mobility Scale Score:_____ and due to high risk of falling with Tinetti Balance and Gait total score of _____, unable to return home safely due to significant/pronounced impairment in the patient's ability to perform various BADL including bed mobility, transfers and gait, patient needs 24-hour aide services that cannot be provided in home health care setting due to the intermittent criteria, considerable taxing effort to be in an out-patient therapy, [[unable to navigate stairs in order to enter/exit home safely] and due to the clinical findings identified in this assessment. Patient’s current functional deficit will not result in spontaneous functional recovery, thus necessitating skilled therapy intervention. Patient is expected to materially improve only with the unique skill of a physical therapist.
Patient is not anticipated to spontaneously improve functionally requiring skilled physical therapy interventions in order to address functional deficits.

Patient will be undergoing intensive physical therapy treatment with series of systematic planned physical movements and progressive motor training intended to improve function, enhance mobility, remediate impairments, and reduce risk of falling in order to enable the patient to perform safe and effective transfers and mobility.

RESIDENCE: Prior to the most recent hospitalization, the patient lived with _____ in a one/two story home with ___steps to enter with [[[[handrail __ when going up. Stairs inside the house which must be used by the patient to get to the bathroom and bedroom. The bathroom has walk in/ tub shower, ---grab bars, regular/raised toilet seat. Patient was ____ with bed mobility and transfers. DME: Patient has the following adaptive and assistive devices: _____

PREVIOUS TREATMENT: Patient initially received minimal acute rehabilitation during the most recent hospitalization.

_____________________

CURRENT REFERRAL: Patient is admitted to the hospital and treated for ---. Patient was referred upon discharge to sub-acute rehabilitation due to ______. Patient developed remarkable deterioration in bed mobility, transfers and gait due to the complexity of the patient's medical condition requiring subacute interventions. Clinical physical therapy assessment includes: impaired static and dynamic standing balance, gait deficit, bilateral LE muscle weakness affecting mobility, pain interfering with movements, muscle guarding, high fall risks. These clinical problems resulted in pronounced functional deterioration, as evidenced by considerable deficits and deterioration in sit <-> stand and bed <-> chair transfer, bed mobility, gait on even and uneven surfaces, [[[navigating stairs]]]] necessitating skilled physical therapy treatment.

PRECAUTION: Time Preference: Projected D/C Date: D/C location: DME: FI:

STANDARDIZED TESTS:

Tinetti Performance Oriented Mobility Assessment Total Score for Balance and Gait: ___/28 (Balance: /16 and Gait /12). Risks Indicators: equal or less than 18 is HIGH RISK for fall, 19-23 is MODERATE RISK for fall, equal or greater than 24 is LOW RISK for fall.

Elderly Mobility Scale Score:__/20 Scores under 10 – generally these patients are dependent in mobility manoeuvres; require help with basic ADL, such as transfers, toileting and dressing. Scores between 10 – 13 – generally these patients are borderline in terms of safe mobility and independence in ADL i.e. they require some help with some mobility manoeuvres. Scores 14 and over – generally these patients are able to perform mobility manoeuvres alone and safely and are independent in basic ADL.

CLINICAL IMPRESSIONS: Patient has marked decline in bed mobility, transfers and gait due to the medically complex conditions for which the patient received inpatient hospital services. The patient requires skilled services on a daily basis and can be furnished/rendered, as a practical matter, only on an in-patient basis specifically in a SNF secondary to the patient's inability to return home safely Elderly Mobility Scale Score of _____ and due to high risk of falling with Tinetti Balance and gait score of _____, unable to return home safely due to considerable/substantial impairment in the patient's ability to perform functional transfers and gait, patient requires 24-hour aide services that cannot be provided in home health setting due to the intermittent criteria, limited assist from caregiver, excessive physical hardship to be in an out patient therapy basis, unable to negotiate stairs in order to enter/exit home safely and due to the identified clinical objective problems. Patient’s present functional deficits will not result in spontaneous functional recovery, thus necessitating skilled therapy intervention. Patient is expected to improve functionally only with the unique skill of a physical therapist.

Patient will be treated with skilled physical therapy with the focus on planned motor training on an incremental basis to augment loss of function in order to improve physical ability through progressive functional training.

RESIDENCE: Prior to the most recent hospitalization, the patient lived with _____ in a one/two story home with ___steps to enter with [[handrail on the __ when going up. Stairs inside the house which must be used by the patient to get to the bathroom and bedroom. Bathroom has walk in/ tub shower, ---grab bars, regular/raised toilet seat. Patient was ____ with bed mobility, transfers and gait. DME: Patient has the following adaptive and assistive devices: _____

PREVIOUS TREATMENT: Patient initially received acute rehabilitation during the most recent hospitalization.

_____________________________

CURRENT REFERRAL Patient was hospitalized and received acute medical care secondary to__. Patient was referred to sub-acute rehabilitation due to --. Patient developed a substantial decline in bed mobility, transfers and gait from the medically complex conditions. Clinical objective problems include gait deficit, muscle weakness affecting mobility, equilibrium or balance deficit, pain interfering with movements, tenderness, muscle spasm, muscle guarding, high fall risks. These clinical problems have resulted in significant functional deterioration, as evidenced by a remarkable deficit in sit <-> stand and bed <-> chair transfer, bed mobility, gait on level surface, [[[navigating stairs]]]] requiring skilled physical rehabilitation.

marked deficit in moving around in bed with scooting, bridging, bed rolling side to side and moving from lying to sitting and sitting to lying; sit to stand and bed< > chair transfers; ambulate on level surface and negotiating steps]]]

PRECAUTION: Time Preference: Projected D/C Date: D/C location: DME: FI:

STANDARDIZED TESTS:

Tinetti Performance Oriented Mobility Assessment Total Score for Balance and Gait: ___/28 (Balance: /16 and Gait /12). Risks Indicators: equal or less than 18 is HIGH RISK for fall, 19-23 is MODERATE RISK for fall, equal or greater than 24 is LOW RISK for fall.

Elderly Mobility Scale Score:__/20 Scores under 10 – generally these patients are dependent in mobility maneuvers; require help with basic ADL, such as transfers, toileting, and dressing. Scores between 10 – 13 – generally these patients are borderline in terms of safe mobility and independence in ADL i.e. they require some help with some mobility maneuvers. Scores 14 and over – generally these patients are able to perform mobility maneuvers alone and safely and are independent in basic ADL.

Berg Balance Scale Score:___/56. Interpretation: 41-56 = low fall risk, 21-40 = medium fall risk, 0 –20 = high fall risk

CLINICAL IMPRESSIONS: Patient recently exhibited notable deterioration in bed mobility, transfers, and gait from the medically complex conditions. Patient necessitates skilled physical therapy interventions that can be provided on a daily basis and as a practical matter only in a SNF in view of the patient's inability to return home safely secondary to Elderly Mobility Scale Score:_____ and high risk of falling with Tinetti Balance and Gait total score of _____, unable to return home safely due to marked impairment in the patient's ability to perform functional mobility , patient needs 24-hour aide services that cannot be provided in home health care setting due to the intermittent criteria, inadequate/ insufficient help from caregiver, remarkable taxing effort to be in an out-patient therapy, [[unable to navigate stairs in order to enter/exit home safely]. Patient’s current functional deficit will not result in spontaneous functional recovery necessitating skilled therapy intervention. Patient is expected to materially improve only with the unique skill of a physical therapist.
Patient is not anticipated to spontaneously improve functionally requiring skilled physical therapy interventions in order to address functional deficits.

Patient will be participating in an intensive physical therapy treatment with frequent adjustments and with progressive motor training through - intended to improve function, enhance mobility, remediate impairments, and reduce the risk of falling in order to enable the patient to perform safe and effective transfers and mobility.

RESIDENCE: Prior to the most recent hospitalization, patient lived with _____ in a one/two story home with ___steps to enter with [[[[handrail __ when going up. Stairs inside the house which must be used by the patient to get to the bathroom and bedroom. The bathroom has walk in/ tub shower, ---grab bars, regular/raised toilet seat. Patient was ____ with bed mobility and transfers. DME: Patient has the following adaptive and assistive devices: _____

PREVIOUS TREATMENT: Patient initially received acute rehabilitation during the most recent hospitalization.

_____________________________

Patient has muscle weakness with decreased contractile mechanism of BLE musculature which resulted in a diminished performance with low-intensity physical activity.
diminished response of BLE musculature during physical activity as evidenced by progressive decrement with the amplitude of motor unit potentials to carry on desired activity such as supine<> sit at the edge of the bed, bed< >chair transfers and gait
Patient has diminished muscular strength on bilateral LE both statistically and dynamically against an imposed load leading to marked decreased performance in functional gait and mobility.
- Patient has noticeable muscle weakness with decreased contractile mechanism of BLE musculature which developed due to a decrease in energy stores and insufficient oxygen which resulted in a diminished performance with low-intensity physical activity.

HPP

CURRENT REFERRAL :This is a case of ___y/o, male/female, right-handed/left-handed, Caucasian/African- American???? patient who was admitted in the hospital from___to ____ and received acute medical care for the following diagnoses: . Patient was referred from the Hospital to sub-acute rehabilitation due to ---------. Patient developed a substantial decline in bed mobility, transfers and gait in the past ___ weeks due to the medically complex conditions requiring skilled physical therapy interventions. Clinical objective problems include: gait deficit, muscle weakness affecting mobility, equilibrium or balance deficit, pain interfering with movements, tenderness, muscle spasm, muscle guarding, high fall risks. These clinical problems have resulted in significant functional deterioration, as evidenced by a remarkable deficit in sit <-> stand and bed <-> chair transfer, bed mobility, gait on level surface, [[[navigating stairs]]]] requiring skilled physical rehabilitation.

marked deficit in moving around in bed with scooting, bridging, bed rolling side to side and moving from lying to sitting and sitting to lying; sit to stand and bed< > chair transfers; ambulate on level surface and negotiating steps]]]
PRECAUTION: Time Preference: Projected D/C Date: D/C location: DME: FI:

STANDARDIZED TESTS:

Tinetti Performance Oriented Mobility Assessment Total Score for Balance and Gait: ___/28 (Balance: /16 and Gait /12). Risks Indicators: equal or less than 18 is HIGH RISK for fall, 19-23 is MODERATE RISK for fall, equal or greater than 24 is LOW RISK for fall.

Elderly Mobility Scale Score:___/20 Scores under 10 – generally these patients are dependent in mobility manoeuvres; require help with basic ADL, such as transfers, toileting and dressing. Scores between 10 – 13 – generally these patients are borderline in terms of safe mobility and independence in ADL i.e. they require some help with some mobility manoeuvres. Scores 14 and over – generally these patients are able to perform mobility manoeuvres alone and safely and are independent in basic ADL.

Berg Balance Scale Score:___/56. Interpretation: 41-56 = low fall risk, 21-40 = medium fall risk, 0 –20 = high fall risk

CLINICAL IMPRESSIONS: Patient recently deteriorated in bed mobility, transfers and gait to______due to the medically complex conditions. Patient requires skilled physical therapy interventions on a daily basis and can be provided, as a practical matter, only on an inpatient basis in a SNF in lieu to the patient's inability to return home safely with Elderly Mobility Scale Score:_____ and due to high risk of falling with Tinetti Balance and Gait total score of _____, unable to return home safely due to significant/pronounced impairment in the patient's ability to perform various BADL including bed mobility, transfers and gait, patient needs 24-hour aide services that cannot be provided in home health care setting due to the intermittent criteria, inadequate/ insufficient help from caregiver, primary caregiver has ____which limit the assistance provided to the patient, considerable taxing effort to be in an out-patient therapy, [[unable to navigate stairs in order to enter/exit home safely] and due to the clinical findings identified in this assessment. Patient’s current functional deficit will not result in spontaneous functional recovery, thus necessitating skilled therapy intervention. Patient is expected to materially improve only with the unique skill of a physical therapist.
Patient is not anticipated to spontaneously improve functionally requiring skilled physical therapy interventions in order to address functional deficits.

Patient will be undergoing intensive physical therapy treatment with series of systematic planned physical movements and progressive motor training intended to improve function, enhance mobility, remediate impairments, and reduce risk of falling in order to enable the patient to perform safe and effective transfers and mobility.

RESIDENCE: Prior to the most recent hospitalization, the patient lived with _____ in a one/two story home with ___steps to enter with [[[[handrail __ when going up. Stairs inside the house which must be used by the patient to get to the bathroom and bedroom. The bathroom has walk in/ tub shower, ---grab bars, regular/raised toilet seat. Patient was ____ with bed mobility and transfers. DME: Patient has the following adaptive and assistive devices: _____

PREVIOUS TREATMENT: Patient initially received acute rehabilitation during the most recent hospitalization.

_____________________

CURRENT REFERRAL :Patient is ___y/o male/female, right handed/left handed, Caucasian/African- American??? admitted to the hospital from___to ____ where the patient received treatment for the following hospital diagnoses/and treated for the following hospital diagnoses: ____ . Patient was referred upon discharge from the Hospital to sub-acute rehabilitation due to ______. Patient developed remarkable deterioration in bed mobility, transfers and gait in the past ___ weeks due to the medically complex conditions requiring skilled physical therapy interventions. Clinical physical therapy assessment includes: impaired static and dynamic standing balance, gait deficit, bilateral LE muscle weakness affecting mobility, pain interfering with movements, muscle guarding, high fall risks. These clinical problems resulted in pronounced functional deterioration, as evidenced by considerable deficits and deterioration in sit <-> stand and bed <-> chair transfer, bed mobility, gait on even and uneven surfaces, [[[navigating stairs]]]] necessitating skilled physical therapy treatment.

PRECAUTION: Time Preference: Projected D/C Date: D/C location: DME: FI:

STANDARDIZED TESTS:

Tinetti Performance Oriented Mobility Assessment Total Score for Balance and Gait: ___/28 (Balance: /16 and Gait /12). Risks Indicators: equal or less than 18 is HIGH RISK for fall, 19-23 is MODERATE RISK for fall, equal or greater than 24 is LOW RISK for fall.

Elderly Mobility Scale Score:__/20 Scores under 10 – generally these patients are dependent in mobility manoeuvres; require help with basic ADL, such as transfers, toileting and dressing. Scores between 10 – 13 – generally these patients are borderline in terms of safe mobility and independence in ADL i.e. they require some help with some mobility manoeuvres. Scores 14 and over – generally these patients are able to perform mobility manoeuvres alone and safely and are independent in basic ADL. Berg Balance Scale Score:___/56. Interpretation: 41-56 = low fall risk, 21-40 = medium fall risk, 0 –20 = high fall risk

CLINICAL IMPRESSIONS: Patient has marked decline in bed mobility, transfers and gait to______due to the medically complex conditions such as _____for which the patient received inpatient hospital services. The patient requires skilled services on a daily basis and can be furnished/rendered, as a practical matter, only on an in-patient basis specifically in a SNF secondary to the patient's inability to return home safely Elderly Mobility Scale Score of _____ and due to high risk of falling with Tinetti Balance and gait score of _____, unable to return home safely due to considerable/substantial impairment in the patient's ability to perform functional transfers and gait, patient requires 24-hour aide services that cannot be provided in home health setting due to the intermittent criteria, limited assist from caregiver, primary caregiver has ____which limit the assistance provided to the patient, excessive physical hardship to be in an out patient therapy basis, unable to negotiate stairs in order to enter/exit home safely and due to the identified clinical objective problems. Patient’s present functional deficits will not result in spontaneous functional recovery, thus necessitating skilled therapy intervention. Patient is expected to improve functionally only with the unique skill of a physical therapist.

Patient will be treated with skilled physical therapy with the focus on planned motor training on an incremental basis to augment loss of function in order to improve physical ability through progressive functional training.

RESIDENCE: Prior to the most recent hospitalization, the patient lived with _____ in a one/two story home with ___steps to enter with [[handrail on the __ when going up. Stairs inside the house which must be used by the patient to get to the bathroom and bedroom. Bathroom has walk in/ tub shower, ---grab bars, regular/raised toilet seat. Patient was ____ with bed mobility, transfers and gait. DME: Patient has the following adaptive and assistive devices: _____

PREVIOUS TREATMENT: Patient initially received acute rehabilitation during the most recent hospitalization.

_____________________________

CURRENT REFERRAL :This is a case of ___y/o, male/female, right-handed/left-handed, Caucasian/African- American???? patient who was admitted in the hospital from___to ____ and received acute medical care for the following diagnoses: . Patient was referred from the Hospital to sub-acute rehabilitation due to ---------. Patient developed a substantial decline in bed mobility, transfers and gait in the past ___ weeks due to the medically complex conditions requiring skilled physical therapy interventions. Clinical objective problems include gait deficit, muscle weakness affecting mobility, equilibrium or balance deficit, pain interfering with movements, tenderness, muscle spasm, muscle guarding, high fall risks. These clinical problems have resulted in significant functional deterioration, as evidenced by a remarkable deficit in sit <-> stand and bed <-> chair transfer, bed mobility, gait on level surface, [[[navigating stairs]]]] requiring skilled physical rehabilitation.

marked deficit in moving around in bed with scooting, bridging, bed rolling side to side and moving from lying to sitting and sitting to lying; sit to stand and bed< > chair transfers; ambulate on level surface and negotiating steps]]]

PRECAUTION: Time Preference: Projected D/C Date: D/C location: DME: FI:

STANDARDIZED TESTS:

Tinetti Performance Oriented Mobility Assessment Total Score for Balance and Gait: ___/28 (Balance: /16 and Gait /12). Risks Indicators: equal or less than 18 is HIGH RISK for fall, 19-23 is MODERATE RISK for fall, equal or greater than 24 is LOW RISK for fall.

Elderly Mobility Scale Score:__/20 Scores under 10 – generally these patients are dependent in mobility maneuvers; require help with basic ADL, such as transfers, toileting, and dressing. Scores between 10 – 13 – generally these patients are borderline in terms of safe mobility and independence in ADL i.e. they require some help with some mobility maneuvers. Scores 14 and over – generally these patients are able to perform mobility maneuvers alone and safely and are independent in basic ADL.

Berg Balance Scale Score:___/56. Interpretation: 41-56 = low fall risk, 21-40 = medium fall risk, 0 –20 = high fall risk

CLINICAL IMPRESSIONS: Patient recently exhibited notable deterioration in bed mobility, transfers, and gait to______due to the medically complex conditions. Patient necessitates skilled physical therapy interventions that can be provided on a daily basis and as a practical matter only in a SNF in view of the patient's inability to return home safely secondary to Elderly Mobility Scale Score:_____ and high risk of falling with Tinetti Balance and Gait total score of _____, unable to return home safely due to marked impairment in the patient's ability to perform functional mobility , patient needs 24-hour aide services that cannot be provided in home health care setting due to the intermittent criteria, inadequate/ insufficient help from caregiver, remarkable taxing effort to be in an out-patient therapy, [[unable to navigate stairs in order to enter/exit home safely]. Patient’s current functional deficit will not result in spontaneous functional recovery necessitating skilled therapy intervention. Patient is expected to materially improve only with the unique skill of a physical therapist.
Patient is not anticipated to spontaneously improve functionally requiring skilled physical therapy interventions in order to address functional deficits.

Patient will be participating in an intensive physical therapy treatment with frequent adjustments and with progressive motor training through - intended to improve function, enhance mobility, remediate impairments, and reduce the risk of falling in order to enable the patient to perform safe and effective transfers and mobility.

RESIDENCE: Prior to the most recent hospitalization, patient lived with _____ in a one/two story home with ___steps to enter with [[[[handrail __ when going up. Stairs inside the house which must be used by the patient to get to the bathroom and bedroom. The bathroom has walk in/ tub shower, ---grab bars, regular/raised toilet seat. Patient was ____ with bed mobility and transfers. DME: Patient has the following adaptive and assistive devices: _____

PREVIOUS TREATMENT: Patient initially received acute rehabilitation during the most recent hospitalization.

_____________________________

Patient has muscle weakness with decreased contractile mechanism of BLE musculature which resulted in a diminished performance with low-intensity physical activity.
diminished response of BLE musculature during physical activity as evidenced by progressive decrement with the amplitude of motor unit potentials to carry on desired activity such as supine<> sit at the edge of the bed, bed< >chair transfers and gait
Patient has diminished muscular strength on bilateral LE both statistically and dynamically against an imposed load leading to marked decreased performance in functional gait and mobility.
- Patient has noticeable muscle weakness with decreased contractile mechanism of BLE musculature which developed due to a decrease in energy stores and insufficient oxygen which resulted in a diminished performance with low-intensity physical activity.

_____________________

SKILLED JUSTIFICATION: Physical therapy is medically reasonable sand necessary to address patient's loss of function with series of planned progressive physical therapy interventions to increase proprioceptive input, improve muscular contractility, improve coordination and motor control in order to improve ability and safety with transfers and gait.

SKILLED JUSTIFICATION: In order to address clinical problems identified, physical therapy is medically reasonable and necessary for balance rehabilitation, movement coordination training, equilibrium training, stabilization training for the trunk and lower extremities, complex-progressive muscular strengthening, bed mobility transfer training related to sit <-> stand, bed <-> chair training, proprioceptive and kinesthetic training, gait training for even and uneven steps, [[[[[stair training]]]]. Patient’s current functional impairment is expected to deteriorate if not treated with skilled rehabilitation therapy due to [[[[joint adhesion, increase soft tissue restriction, further joint restriction,]], further degradation of muscle strength, further balance deficit, muscular incoordination. Physical therapy is also indicated to reduce the risk of falling and to avert further injury or re-hospitalization. Therefore, the condition of the patient requires the judgment, knowledge, and skills of a qualified physical therapist.

SKILLED JUSTIFICATION: Physical therapy is reasonable and necessary to promote safety awareness, increase level of independence with gait, improve static and dynamic balance, enhance fall recovery, facilitate anticipatory reactions, promote motor control, increase muscular coordination, promote ankle strategies, improve trunk and hip and knee stability, facilitate functional mobility, improve gait coordination and controlled mobility, improve balance during non-movement activities (standing or sitting). The patient is expected to materially improve functionally only with the unique skill of a physical therapist.

SKILLED JUSTIFICATION:Physical therapy is medically reasonable and necessary for balance rehabilitation, movement coordination training, non-equilibrium training for the trunk and lower extremities, complex-progressive muscular strengthening, bed mobility transfer training related to sit <-> stand, bed <-> chair training, proprioceptive and kinesthetic training, gait training for even and uneven steps, [[[[[stair training]]]]. Patient’s current functional impairment is expected to deteriorate if not treated with skilled rehabilitation therapy due to [[[[joint adhesion, increase soft tissue restriction, further joint restriction, advanced limitation of motion, joint deformity/ permanent disability]]], further degradation of muscle strength, further balance deficit, muscular incoordination. Physical therapy is also indicated to reduce the risk of falling and to avert further injury or re-hospitalization. Therefore, the condition of the patient requires the judgment, knowledge, and skills of a qualified physical therapist. Moreover, patient’s functional impairment will not result in spontaneous functional recovery, thus necessitating skilled therapy intervention.
(As Applicable) Patient’s functional impairment has the probability to make significant improvement as a consequence of therapy as determined in this skilled assessment.

____________________

RCSS PMN: remarkable, considerable, substantial, significant, pronounced, marked, noticeable

Patient was previously undergoing subacute rehabilitation but interrupted by the most recent in-patient hospital stay.

Patient requires skilled physical therapy rehabilitation service to be performed safely and/or effectively only by or under the supervision of a physical therapist as ordered by Dr ______ due to the complexity and sophistication of the service which requires the knowledge, judgment, and skills of a physical therapist. The services are rendered for ________(condition ) for which the patient received inpatient hospital services. The patient requires skilled services on a daily basis and can be provided, as a practical matter, only on an inpatient basis in a SNF in lieu to the patient's inability to return home safely due to high risk of falling with timed up and go test score of ____, Tinetti Balance and gait score of _____, unable to return home safely due to significant impairment in the patient's ability to perform various BADL including transfers and gait, patient requires 24-hour aide services that cannot be provided in home health setting due to intermittent criteria, limited help from caregiver, primary caregiver has ____which limit the assistance provided to the patient, excessive physical hardship to be in an out patient therapy basis, unable to navigate stairs in order to enter/exit home safely and due to the identified clinical objective problems. Furthermore, the services are reasonable and necessary for the treatment consistent with the nature and severity of the patient’s illness or injury, the patient’s particular medical needs, and accepted standards of medical practice due to the following clinical objective problems: gait deficit, muscle weakness affecting mobility, equilibrium or balance deficit, pain interfering with movements, tenderness, muscle spasm, muscle guarding, high fall risks. These clinical problems have resulted in significant functional deterioration, as evidenced by remarkable deficit in activities of daily living, which include but not limited to deterioration in sit <-> stand and bed <-> chair transfer, bed mobility, gait on even and uneven surfaces, [[[[navigating stairs]]]]], requiring physical assistance.

CLINICAL IMPRESSIONS: Patient has marked decline in bed mobility, transfers and gait to______due to the medically complex conditions. Patient requires skilled physical therapy rehabilitation service to be performed safely and/or effectively only by or under the supervision of a physical therapist as ordered by Dr ______ due to the complexity and sophistication of the service which requires the knowledge, judgment, and skills of a physical therapist. The services are rendered for ________(condition ) for which the patient received inpatient hospital services. The patient requires skilled services on a daily basis and can be provided, as a practical matter, only on an inpatient basis in a SNF in lieu to the patient's inability to return home safely due to high risk of falling with timed up and go test score of ____, Tinetti Balance and gait score of _____, unable to return home safely due to significant impairment in the patient's ability to perform various BADL including transfers and gait, patient requires 24-hour aide services that cannot be provided in home health setting due to intermittent criteria, limited help from caregiver, primary caregiver has ____which limit the assistance provided to the patient, excessive physical hardship to be in an out patient therapy basis, unable to navigate stairs in order to enter/exit home safely and due to the identified clinical objective problems. Patient’s present functional deficits will not result in spontaneous functional recovery, thus necessitating skilled therapy intervention. Patient is expected to improve functionally only with the unique skill of a physical therapist.

Clinical objective problems include gait deficit, muscle weakness affecting mobility, equilibrium or balance deficit, pain interfering with movements, tenderness, muscle spasm, muscle guarding, high fall risks. These clinical problems have resulted in significant functional deterioration, as evidenced by remarkable deficit in activities of daily living, which include but not limited to deterioration in sit <-> stand and bed <-> chair transfer, bed mobility, gait on even and uneven surfaces, [[[[navigating stairs]]]]], requiring physical assistance.

These clinical problems have resulted in substantial functional decline, as evidenced by marked deficit in activities of daily living with deterioration in sit <-> stand and bed <-> chair transfer, bed mobility, gait on even and uneven surfaces, [[[[negotiating stairs]]]]], requiring skilled physical therapy.

Furthermore, the services are reasonable and necessary for the treatment consistent with the nature and severity of the patient’s illness or injury, the patient’s particular medical needs, and accepted standards of medical practice due to the following clinical objective problems

Patient’s functional impairment will not result in spontaneous functional recovery as the patient gradually resumes normal activities, thus necessitating skilled therapy intervention. Patient is expected to materially improve functionally only with the unique skill of a physical therapist. Patient is temporarily receiving limited assistance while recovering from the current illness.

The patient has the following complexities which require longer treatment than usual due to multiple medical conditions such as _______which affect the healing process, __ years old and very frail, takes multiple medications that affects, follows 1-2 step commands only, severity and acuity of the illness, multiple conditions such as_______, has a poor short term memory, dementia delays the response of the patient.

Transfers

BED MOBILITY/TRANSFER STATUS

Supine<> sit at the edge of the bed training required : _ physical assist, sit<>stand training required _ physical assist, bed< >chair transfer training required: _ physical assist.

BEDRISE

Bed Mobility Task: trained the patient in performing arm reach and trunk lift to improve bed mobility; patient was instructed to reach forward and over the side of exit with the opposite arm while lifting the trunk slightly in order to improve elevating and turning the trunk for the initial part of bed rise

Bed Mobility Task: trained the patient in performing lateral leg movement to improve bed rise; patient was instructed to move one leg toward the side of exit and then the other leg to the opposite side to improve moving hips/legs laterally for initial part of bed rise

Bed Mobility Task: trained the patient in performing unilateral heel raise; patient was positioned with one knee and hip flexed and the opposite leg extended (SLR position). Patient was instructed to raise the heel of the straight leg 4-6 inches off the bed and hold for 3 seconds, then repeated on the opposite side to improve elevating the legs in preparation for bed rise

Bed Mobility Task: trained the patient in performing roll to side lying; patient was instructed to roll onto the side by pushing the opposite heel down to improve moving the trunk and pelvis onto the side with foot push in preparation for bed rise

Bed Mobility Task: trained the patient in performing side lying to sit. Patient was positioned in side lying with hips and knees flexed and heels supported on the bed; patient was instructed to push down with the elbow in contact with the bed and the opposite hand and come to sit with legs dangling off the edge of the bed to improve alternate way to rise after rolling onto the side

Bed Mobility Task: trained the patient in performing bed rise with weight on hip and then hold. Patient was positioned in sitting at the edge of the bed with legs dangling and arms folded across the chest. Patient was instructed to place all weight on one hip, lean as far as possible to one side, and hold for 3 seconds, then repeated to the opposite side to improve balancing trunk on one side of the hip necessary for bed mobility

Bed Mobility Task: trained the patient in performing trunk elevation by upper extremity extension with patient's position in supine. Patient was instructed to raise the trunk by extending the arms first then pushing off and extending the elbows to improve elevating the trunk using shoulder and elbow extension

Bed Mobility Task: trained the patient in performing bridging; positioned patient in hook lying with hands at the sides, then patient was instructed to raise buttocks off the bed and hold for 3 seconds to improve elevating the pelvis and utilizing arm support necessary for bed mobility

Bed Mobility Task: trained the patient in performing supine to sit, wherein patient was instructed to slide forward to the edge of the bed, shifting the weight from one hip to the other with the assistance of both arm to improve moving the pelvis forward

CHAIR RISE

Task: trained the patient on how to properly slide forward for sit <> stand. Patient was instructed to slide forward to the edge of the seat, shifting the weight from one hip to the other, wherein both armrests used for assistance to improve moving the pelvis forward on the seat

Task: trained the patient in performing the required trunk flexion for sit <> stand. Patient was instructed to lean forward from the hip joint as far as possible keeping the neck and upper back straight with both armrests used for assistance to improve leaning forward

Task: trained the patient in performing trunk rock and lift. Patient was in seated position at the edge of the chair, then instructed to rock back and forth and lift the buttocks off the seat. Both armrests were used for assistance. Training was conducted to develop sufficient trunk momentum to elevate the buttocks off the seat. Activity was repeated 15 times with corrections

Task: trained the patient in performing pelvic elevation. Patient was seated back in chair with legs extended out in front to minimize leg assistance, patient was then instructed to push down on both armrests and elevate the pelvis off the seat to improve using the arms only to help elevate the pelvis

Task: trained the patient with flexed configuration after lift-off. Patient was instructed to rise from the seat using the armrests and keep the buttocks off the seat without rising to a full standing position with hips and knees remained flexed. This is to improve balancing at the critical moment of lift-off from the seat

Task: trained the patient in performing rising from chair with hands. Patient was instructed to rise from the seat using hands to improve rising from the chair in a comfortable an safe manner

Task: trained the patient in performing rise from chair without hands - patient was then instructed to rise from the seat using safe strategy except for using hands. Training was conducted to improve rising from the chair in a safe manner without using hands

Task: trained the patient in performing hip and knee bends for sit <-> stand. Positioned patient in standing. patient was instructed to bend the hips and knees as far as possible and then raise up again to improve knee and hip extension at the final phase of chair rise

STERNAL

Patient was instructed not to lift, push or pull objects heavier than 5 pounds without further clearance from the physician. Explained to the patient that a half-gallon of milk is about 4 pounds. Educated that the sternum is not fully integrated at this time with good new bone regeneration and lifting heavy weight may separate bones and the sternum wires could work loose.

In order to adhere with the sternal precaution, patient was instructed to use the log roll technique when getting out of bed and to refrain from using the arms and hands to pull self up. Patient was then instructed to rise from bed, use the log roll technique by simply lying on the back, and then roll onto one side and allow the legs to fall slowly off the edge of the bed, and allow the momentum to assist the upper body to rise up, taking care not to push or pull with the arms.

Patient was educated to use the legs to stand up from a chair so as not to disrupt the healing sternal incision. Patient was instructed to slide the heels back so the feet are positioned well under the knees, and place the hands on the thighs. Patient was then instructed to lean forward with the nose over the toes, and rise up, taking care not to push or pull with the arms.

Patient was instructed to roll the shoulders to stretch to decrease stiffness instead of placing both arms overhead in order to adhere with the rules of the sternal precautions post surgery. Instead of reaching overhead to stretch, instructed to the shoulder blades forward and back with the arms by the side to avoid excessive separation of the breastbone and the chest incision.

Patient was instructed to utilize a pillow to splint when coughing. Patient was educated that coughing can be painful after open heart surgery, and coughing forcefully can place stress and strain through the sternum. Instructed to place a pillow over the chest and hug it tightly whenever feeling the need to cough or sneeze.

Response to Tx

1) Skilled therapeutic activities require the involvement of a therapist to meet the patient’s needs, promote recovery, and ensure medical safety related to the patient’s illness.

2) The skill of therapist is still needed to manage the appropriateness of the therapeutic activities and hands-on techniques.

3) Therapist is still needed to carry out the skilled therapeutic procedures to improve and achieve the fundamental goals.

4) Patient’s condition continues to materially improve in a reasonable and predictable time, as set in the plan of care.

5) Skilled therapy is concurrent with the patients’ care plan.

6) Treatment of the patient’s illness can only be carried out by the skilled therapist due to hands-on technique and complexity of the plan of care.

7) Service cannot be carried out by non-skilled personnel due to the inherent complexity of the treatment regimen provided.

8) In view of the patient’s overall conditions, skilled management provided by the therapist is due to the inherent level of sophistication.

9) The skill of therapist is still needed due to special medical condition; patient is susceptible to pathological bone fracture due to osteoporosis.

10) Continue restorative physical therapy program for skilled intervention and adjustment of current therapeutic regimen.

11) Continue therapy for the implementation of the therapeutic intervention tailored for the specific needs of the patient.

12) Treatment provided specifically directed to an active written treatment regimen approved by the physician.

13) Patient continues to improve and require therapy based on the clinical findings, extent of loss of function, social considerations, and patient overall function.

14) Assessment on patient’s progress toward set goals established in the plan of care was performed for the patient’s physical impairment.

15) Patient continues to require broad range of skilled rehabilitative techniques to improve movements and physical function.

16) Patient’s treatment activities are directed to improve the restriction of mobility strength, balance or coordination affecting ADL.

17) Current treatment addresses the patient’s specific functional needs for recovery, skilled intervention was upgraded today.

18) Patient necessitates further treatment to achieve optimum rehabilitation potential.

19) Patient has the capacity to learn the instructions given to improve function. New instructions were given to improve ADL.

20) Patient is expected to return to the highest level of function as described in the plan of care.

21) Patient demonstrates improvements toward set goals and requires further treatment to achieve functional mobility

22) Patient is able to participate and continue to benefit from skilled intervention given.

23) Patient continues to improve towards the established goals and makes significant improvement to increase functionality with skilled therapy.

24) Patient treatment has not reached plateau and continues to make functional improvement with skilled therapy.

25) Patient’s loss of function is not expected to improve over time without skilled physical therapy services.

26) Patient makes great strides with the skilled therapy intervention, but requires further skilled care to achieve prior level of function..

27) Patient is compliant with the treatment plan and continues to respond with skilled therapy.

28) Patient continues to gain functional improvement as a result of the physical therapy treatment.

29) Physical therapy treatment is concurrent with the established plan of treatment.

30) Patient responds with the skilled therapy intervention geared to improve mobility.

31) Patient actively participates in the skilled treatment regimen designed to increase function in connection with the plan of treatment.

32) Patient requires further skilled treatment to attain maximum rehab potential.

33) Skilled rehab training is geared to improve the functional capacity of the patient.

34) Patient actively involves in the treatment provided through skilled therapy interventions.

35) Patient shows functional progress with the treatment, but requires further therapy treatment to reach functional goals.

36) Patient exhibits favorable response with the skilled treatment regimen provided.

37) Patient demonstrates progress in lined with the attainment of the established goals.

39) Patient necessitates further skilled treatment to achieved functional goals as set in the plan of care.

40) Patient exhibits good rapport with the therapist and favorable response with the treatment to improve functional goals.

41) Patient has attained maximum physical rehabilitation potential, as of this visit.

42) Patient has achieved optimum physical rehabilitation potential, as of this visit.

43) Patient has completed treatment and achieved the highest functional rehab potential.

44) Patient has completed comprehensive physical rehabilitation treatment as of this visit.

45) Patient has achieved optimum functional rehabilitation potential as of this visit.

GAIT MUSCLES

Gait training was focus to improve swing phase by the contralateral limb with single support by the ipsilateral limb to support body weight in the sagittal and coronal planes
Gait training was focused on temporal gait parameters such as stride and step duration and cadence; spatial gait parameters with the distance covered between two consecutive initial contacts (step and stride length).
Gait training was focus on the initial contact/heel strike to improve the transfer of weight onto the new stance leg while attenuating shock, improving gait velocity and stability
Gait training was focus to improve knee stability and shock absorption achieved by eccentric quadriceps contractions during loading response of gait
Gait training was focus on the stance phase of gait (i.e., initial contact, loading response, mid stance, terminal stance, preswing) to improve quality of gait

Erector Spinae

facilitation of the erector spinae from flexion toward extension of the vertebral column and head to promote safe and effective gait pattern

Hip Adductor

facilitation of the hip adductors towards drawing lower extremity towards axis or midline of body to promote safe and effective gait pattern

Abductor

facilitation of the hip abductors towards lower extremity abduction at hip joint to minimize the impact of loading at the hip during single support thus promoting safe and effective gait pattern

Hip flexor

facilitation of the hip flexors by flexion of the femur onto the lumbo-pelvic complex to improve initiating the swing phase of gait to promote safe and effective gait pattern
facilitation of the hip flexors (iliopsoas, sartorius, rectus femuris, tensor fasciae latae) including the medial compartment of the thigh (gracilis, adductor longus/brevis, and pectinous) to improve initiating the swing phase of gait to promote safe and effective gait pattern

Hip extensors

facilitation of the hip extensors (i.e.,gluteus maximus muscle, Semimembranosus, semitendinosus, long head of the biceps femuris) which are active during stance phase to promote a safe and effective gait pattern
facilitation of the hip extensors (i.e.,gluteus maximus muscle, Semimembranosus, semitendinosus, long head of the biceps femuris) to assist in stabilizing the lower extremity during stance phase for a safe and effective gait pattern
facilitation of the hip extensors to control forward trunk movement during stance phase for a safe and effective gait pattern
facilitation of the gluteus maximus towards extension of thigh to promote safe and effective gait pattern

Knee Flexors

facilitation of the knee flexors (hamstrings, gastrocnemius, gracilis, sartorius, and poplites) to assist foot clearance during midswing promoting a safe and effective gait pattern
Facilitation muscle strengthening of the knee flexors (hamstrings, gastrocnemius, gracilis, sartorius, and poplites) to assist in shock absorption during heel strike promoting a safe and effective gait pattern
facilitation of the knee flexors (hamstrings, gastrocnemius, gracilis, sartorius, and poplites) to assist in shock absorption during initial contact promoting a safe and effective gait pattern
Facilitation of the knee flexors (hamstrings, gastrocnemius, gracilis, sartorius, and poplites) to assist in shock absorption during the stance phase promoting a safe and effective gait pattern

Knee Extensors

facilitation of the knee extensors (rectus femoris, vastus lateralis, vastus intermedius, vastus medialis) contributing to forward propulsion to promote a safe and effective gait pattern

Hamstrings

facilitation of the hamstring muscles to assist in decelerating the lower extremity in the late swing phase to promote a safe and effective gait pattern

Quadriceps

Facilitation of the quadriceps femoris muscle to assist in forward propulsion of the lower extremity promoting a safe and effective gait pattern

Anterior Tibialis

facilitation of the anterior tibialis muscle to assist in eccentric lowering of the foot promoting a safe and effective gait pattern
facilitation strengthening of the anterior tibialis muscle to assist in eccentric lowering of the foot during foot flat promoting a safe and effective gait pattern
facilitation of the anterior tibialis muscle to assist in eccentric lowering of the foot during the loading response promoting a safe and effective gait pattern
activation of the anterior tibialis muscle to assist in eccentric lowering of the foot promoting a safe and effective gait pattern

Plantar Flexors

facilitation of the plantar flexors to assist in initial push off after heel strike promoting a safe and effective gait pattern

Gastrocnemius/Soleus

facilitation of the gastrocnemius-soleus to assist in the concentric rising of the heel during toe off promoting a safe and effective gait pattern
facilitation of the tricpes surae to assist in the concentric rising of the heel during push off promoting a safe and effective gait pattern

Phases of Gait

patient performed series of rhythmic, alternating movements of upper and lower extremities with the trunk leading to forward progression of the center of gravity
focus on performing proper gait cycle which begins from the time the foot touches the ground to the time the same foot touches the ground for the second time to promote proper gait pattern
focus on the stance phase of gait which specifically from initial contact (heel strike) to toe off representing about 60% gait cycle (Initial contact, Loading response, Mid-stance, Terminal stance, Pre-swing) with periods of double stance 10% each -at these times the body's centre of gravity is at its lowest.

=Loading Response

ground reaction force vectors (GRFV)

focus on loading response of gait to improve ground reaction force with a plantar flexion moment at the ankle joint and flexion moment at the knee and hip of the stance leg
focus on loading response of gait with eccentric activity in the ankle dorsiflexors and eccentric activity in the knee extensors and isometric activity in the hip extensors of the stance leg

=Midstance

facilitation of midstance orientation of ground reaction force vector (GRFV) in sagittal plane located anterior to knee and ankle joint

and posterior to hip joint

facilitation midstance during stance phase with an extensor moment at the knee and an extensor moment at the hip
facilitation of midstance phase of gait with eccentric activity in the ankle plantarflexors while maintaining passive force in the posterior knee structures as they elongate during knee extension.

*facilitation of midstance with ground reaction force with dorsiflexor moment at the ankle joint and eccentric activity in the hip flexors

=Terminal Stance

facilitation of the terminal stance phase of gait with orientation of ground reaction force vector (GRFV) in sagittal plane located in the anterior to ankle joint, anterior to knee joint, and posterior to hip joint
facilitation of the terminal stance phase of gait considering the ground reaction force with dorsiflexor moment at the ankle joint, an extensor moment at the knee, and an extensor moment at the hip
facilitation of the plantar flexors during termnial stance of gait through isometic contractions, which have acted eccentrically through midstance
facilitation during the termnial stance of gait through continued advancement of the pelvis and lower extremity on the stance leg so the tibia moves anteriorly, which causes the heel to rise at around 35 to 40 percent of the gait cycle
facilitation of the hip flexors with eccentric contraction while developing passive force in the posterior knee structures as they elongate during knee extension to improve terminal stance phase of gait

Preswing

focus on preswing phase of gait considering the orientation of ground reaction force vector (GRFV) in sagittal plane located anterior to ankle joint, posterior to knee joint

and hip joint during the preswing for an effective gait pattern

facilitation of gait during preswing, with ground reaction force with a dorsiflexor moment at the ankle joint, flexor moment at the knee and an extensor moment at the hip.
facilitation of preswing phase of gait to improve eccentric contraction of the ankle plantarflexors while allowing plantar flexors' activity becomes concentric as they develop the important "push off" force for propulsion.
facilitation of the rectus femuris muscle during preswing to control excessive knee flexion while improving velocity.
facilitation of gait during preswing with continued hip flexor activity as the hip flexors' eccentric terminal stance activity changes to isometric, then concentric activity during preswing and initial swing.

INITIAL SWING 1-Initial swing (Acceleration) Facilitation of the initial swing during swing phase of gait while the hip is in flexion and external rotation

Facilitation of the knee flexors since flexion of the knee is necessary for the swinging limb to clear the ground as it moves forward.

MIDSWING Facilitation of the Mid-swing (the middle third of the swing phase from 73 to 87% of the gait cycle) from the time the swing foot is opposite the stance limb to when the tibia is vertical.

Facilitation of midswing which begins from maximum knee flexion (when the swing limb is under the body) until the swing limb passes the stance limb and the tibia becomes in a vertical position.

TERMINAL SWING Facilitation of the terminal swing (the final third of the swing phase from 78 to 100% of the gait cycle) from the time when the tibia is vertical to initial contact.

3-(terminal swing) Deceleration Gait training with focus to improve rerminal swing/deceleration while the knee is extending in preparation for heel strike, the hip becomes more flexed, the foot in neutral position.

Facilitation of termina lswing as the heel touches the ground, the foot moves into plantar flexion (by the controlling action of the dorsiflexors).

Ranchos

Subphases of Stance Phase

Focus in the Initial Contact of the stance phase of gait to improve the moment when the foot contacts the ground (heel strike) to improve gait pattern.

Facilitation of the Loading response (LR) period to improve when the weight is transferred onto the outstretched limb during the first period of double-limb support (foot flat)

Facilitation of Midstance (MSt) to improve when the body progresses over a single, stable limb

Facilitation of Terminal Stance (TSt) to improve the progression over the stance limb as the body moves ahead of the limb and weight is transferred onto the forefoot.

Facilitation of Pre-Swing (PSw) to improve the unloading of the limb as weight is transferred onto the forefoot (toe-off) to improve gait pattern

Subphases of Swing Phase

Facilitation of Initial swing (ISw) as the thigh begins to advance and as the foot comes up from the floor for an effective gait pattern.

Facilitation of Midswing (MSw) as the thigh continues to advance and the knee begins to extend then the foot clears the ground for an effective gait pattern

Facilitation of Terminal Swing (TSw) as the knee extends and the limb prepares to contact the ground for Initial Contact for an effective gait pattern

Gait Cycle – Functional Tasks

Facilitation of Weight Acceptance (WA) during the period when body weight is rapidly loaded on the outstretched limb so that the impact of the floor-reaction force is absorbed and the body continues in a forward path while stability is maintained during the Initial Contact and Loading Response.

Facilitation of Single Limb Support (SLS) during the period when the body progresses over a single lower extremity then weight is transferred onto the metatarsal heads and the heel comes off the ground during the Mid Stance and Terminal Stance.

Facilitation of Swing Limb Advancement (SLA) during the time when the limb is unloaded and the foot comes off the ground then the limb is moved from behind to in front of the body, reaching to take the next step as transitional movement during Pre-Swing, Initial Swing, Mid Swing and Terminal Swing.

Facilitation of pretibial muscles (anterior tibial, extensor digitorum longus, and extensor hallucis longus) acting prior to and during heel strike with eccentric contraction in order to control the foot while lowering to the ground.

Facilitation of pretibial muscles (anterior tibial, extensor digitorum longus, and extensor hallucis longus) acting prior to and during preswing with concentric contraction in order to improve foot dorsiflexion and clear toes off the ground

• Calf Muscles – Gastrocs, Soleus (FDL, FHL, Posterior tibial) – Foot flat • Eccentric contraction - control of tibia over the foot – Heel off • Concentric contraction – ankle plantarflexion

• Quadriceps – Vastus medialis/lateralis/intermedius, RF – Before Heel Strike • Concentric contraction – initiate knee extension – Swing phase • Eccentric contraction – slow down leg (tibia)

• Hamstrings – Biceps, Semitendinosus, Semimembranosus – Heel strike • Eccentric contraction - HS peaks – protects knee from hyperextension – Swing phase • Concentric contraction – knee flexion, hip extension

• Hip Abductors – Gluteus medius, Gluteus minimus, TFL – Stance phase • Concentric contraction - stabilize pelvis • Hip Adductors – Adductor longus/brevis, Gracilis, Adductor magnus (horizontal and vertical heads) – Early and late stance • Concentric contraction –stabilize pelvis

• Facilitation of the gluteus maximus with eccentric contraction to decelerate forward momentum during stance phase of gait to improve control during gait • Facilitation of the gluteus maximus concentric contraction achieved with hip extension which is essential for the pre-swing phase of gait • Facilitation of the Erector Spinae necessary during heel strike through toe-off to improve trunk posture during gait. • Facilitation of the fibularis longus and brevis concentric contraction necessary for the stance phase of gait to improve medial and lateral stability of the foot • Facilitation of the foot Intrinsics concentric contraction which is essential for the stance phase of gait to support plantar fascia

Fall

Patient has difficulty getting out of bed. The patient was taught that lower the bed so it’s easier to reach the floor. Roll to your side and dangle your feet off the side of the bed before getting up.
Patient walks uncoordinatedly and steps are in a rush. Educated the patient that there’s no need to speed up, slowing down will help maintain an upright posture.
Patient uses a rocking motion to help stand, which tends to be out of balance. Instructed the patient to move to the front of the chair - feet flat on the floor under the shoulders, use chair arms and leg power to lean forward and stand.
Patient was observed while in gait training in one direction, and tried to look elsewhere, which can cause falls. Patient was educated to stop walking to observe surroundings and does it one at a time; instructed the patient that when moving keep focused on where to put the feet.
Patient complains of dizziness when moving from sitting - to standing – when in a rush. Patient was taught to take time to raise legs/arms a few times, and stand slowly. Once standing, take a full breath, relax and “get bearings” before moving on.
Patient wears the wrong slippers, which can cause a fall. Patient was instructed to wear low heeled thin soled enclosed shoes. Slippers should be non-skid.
Patient wears socks alone during transfers. Educated the patient that socks are too slippery to wear alone and may cause fall.
Patient leans on furniture for support, which can be dangerous. Patient was instructed to obtain or use a cane or walker for proper use.
Patient sits in chairs with buttocks lower than the knees, which makes it difficult to stand up. Educated the patient not to use low chairs or add cushions to raise seat height.
Patient was unable to verbalize what to do if she will experience recurrence of dizziness. Patient was instructed to sit down immediately, take slow deep breaths, and exhale fully. Instructed to report to the physician and discuss dizziness to the doctor.
Patient was observed walking in a manner that blocks the view of the feet, which can cause to trip. Patient was educated to know where to place feet and keep them in clear sight.
Patient wears not so clean eyeglasses. Patient was instructed to clean glasses regularly and to use extra care when moving, wearing bi-focals or tri-focals, can hinder depth perception.
Patient sits on the bed and feet are not firmly on the floor, while leaning over, which can cause a fall off the bed . Patient was instructed to sit on a chair when reaching feet like putting socks.
Patient was observed and shortens steps or shuffle the feet during gait. Patient was taught larger steps in a safe environment (on a flat surface, near a stable support if needed). Taking larger steps creates a more stable support base.

STRETCHING

LE Stretching Progressive muscle lengthening of the psoas major, towards extension and internal rotation at hip joint (action: flexion and external rotation in the hip joint) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of iliacus, which arises from the iliac fossa on the interior side of the hip bone, towards hip extension (action: hip flexion) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of gluteus maximus muscle the primary for hip extensor, towards flexion and internal rotation of hip(action: external rotation and extension of the hip joint) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the gluteus maximus since it acts upon the pelvis, supporting it and the trunk upon the head of the femur , towards flexion and internal rotation of hip(action: external rotation and extension of the hip joint) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the gluteus maximus, which causes the body to regain the erect position after stooping assisted in this action by the hamstring muscles , towards flexion and internal rotation of hip(action: external rotation and extension of the hip joint) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of gluteus medius, which originates from the pelvis attached to the femur, towards adduction of the hip (action: abduction of the hip; medial rotation of thigh) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of tensor fasciae latae, which serves to stabilize the pelvis upon the head of the femur, towards thigh extension, internal rotation and adduction (action: Thigh - flexion, medial rotation, abduction, and trunk stabilization) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of tensor fasciae latae the oblique direction of its fibers enables it to abduct the thigh and assists with internal rotation and flexion of hip , towards thigh extension, internal rotation and adduction(action: Thigh - flexion, medial rotation, abduction and trunk stabilization) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of quadratus femoris, which is attached to the inferior portion of the pelvis and connected to the femur bone, towards medial rotation (action: lateral rotation of thigh) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of inferior and superior gemellus - together is called gemelli, towards medial rotation of thigh (action: rotates laterally thigh) to improve ADL activities involving the use of the lower extremities. Progressive muscle lengthening of the piriformis muscle, which occupies a central location in the buttocks, towards internal rotation (action: external rotation of thigh) to improve activities of daily living involving with the use of the lower extremities.

Progressive muscle lengthening of the piriformis muscle, which laterally rotates the extended thigh, towards internal rotation (action: external rotation of thigh) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the piriformis muscle, which is an important muscle in walking for shifting the body weight, towards internal rotation. (action: external rotation of thigh) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the sartorius muscle, which assists in flexion, abduction, lateral rotation of hip, and flexion of knee , towards extension of the hip and knee (action: flexion of the hip and knee) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the sartorius muscle the key muscle used when looking at the bottom of the foot, towards extension of the hip and knee (action: flexion of the hip and knee) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the sartorius muscle also known as the “tailor’s muscle”, which assists in flexion, abduction, lateral rotation of hip, and flexion of knee, towards extension of the hip and knee (action: flexion of the hip and knee) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the quadriceps femoris muscle, which is the greatest extensor of the leg, towards hip extension and knee flexion (action: hip flexion and knee extension) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the quadriceps femoris muscle, which consists of four individual muscles, towards hip extension and knee flexion (action: hip flexion and knee extension) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the biceps femoris muscle, which originates from the pelvis and femur, towards hip flexion and knee extension (action: hip extension, knee flexion) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the semitendinosus muscle, which has a prominent tendon on the back of the knee, towards knee extension and hip flexion (action: flex knee, extend hip joint) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the semimembranosus, which has a deep tendon on the back of the knee that is hard to locate, towards hip flexion and knee extension (action: hip extension and knee flexion) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the pectineus muscle, which is primarily responsible for hip flexion, towards hip extension (action: hip flexion, adduction and medial rotation) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the obturator externus muscle, which passes behind the pelvis, towards abduction and medial rotation (action: adduct thigh, rotate thigh laterally) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the gracilis, towards hip abduction and hip extension (action: hip adduction, hip flexion) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the gracilis, towards hip abduction and hip extension (action: hip adduction, hip flexion) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the adductor a muscle, which consists of 3 individual muscles, towards hip abduction (action: hip adduction) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the adductor magnus a large triangular muscle, situated on the medial side of the thigh, towards hip abduction (action: hip adduction) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the adductor longus muscle, which is located on the medial side of the thigh, towards hip abduction (action: hip adduction) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the adductor brevis, which is located on the medial side of the thigh, towards hip abduction (action: hip adduction) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the tibialis anterior muscle, which acts to keep the leg vertical, towards plantar flexion and eversion of foot at ankle joint (action: dorsiflexion and inversion of ankle) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the triceps surae, which consists of 2 large muscles, towards knee extension and ankle dorsiflexion (action: knee flexion, ankle plantarflexion) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the gastrocnemius muscle, which crosses 2 joints on the lower extremity, towards knee extension and ankle dorsiflexion (action: knee flexion, ankle plantarflexion) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the soleus muscle the deeper of 2 individual muscles, which forms the triceps surae muscle on the leg, towards ankle dorsiflexion (action: ankle plantarflexion) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the soleus muscle, which plays an important role in standing, towards ankle dorsiflexion (action: ankle plantarflexion) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the soleus muscle, which keeps an upright posture, towards ankle dorsiflexion (action: ankle plantarflexion) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the plantaris muscle, towards foot dorsiflexion and knee extension (action: knee flexion, foot plantarflexion) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the plantaris muscle, which may provide biofeedback information to the brain regarding the position of the foot, towards foot dorsiflexion and knee extension (action: knee flexion, foot plantarflexion) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the popliteus muscle, which is also known as the “key muscle” unlocking the femur on the tibia, towards knee flexion (action: lateral rotation of femur on tibia, and flexion of knee) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the peroneus longus muscle, which is also known as the fibularis longus, towards dorsiflexion and inversion of the foot (action: plantarflexion, eversion of foot) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the peroneus brevis muscle, which runs vertically downward on the leg passing behind the lateral malleolus at the side of the foot, towards dorsiflexion and inversion (action: plantarflexion and eversion of foot) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the toe extensors, which consists of two muscles located on top of the foot, towards toe flexion (action: extension of toes) to improve activities of daily living involving with the use of the lower extremities. Progressive muscle lengthening of the flexor digitorum brevis, towards extension of second to fifth toes (action: flexion of second to fifth toes) to improve activities of daily living involving with the use of the lower extremities.

Torso Stretching Progressive Muscle lengthening of splenius capitis muscle, a straplike muscle in the back of the neck and connects the base of the skull to the vertebrae in the neck and upper thorax, towards flexion, rotation and lateral flexion to the opposite side (action: extend, rotate, and laterally flex the head ) to improve ADL activities with the use of the upper extremities.

Progressive muscle lengthening of splenius cervicis muscle, a narrow tendinous band from the spinous processes of the third to the sixth thoracic vertebrae, towards contralateral rotation and lateral bending of the neck to improve activities of daily living involving with the use of the trunk movements. .

Progressive muscle lengthening of erector spinae also known as the sacrospinalis towards flexion of the vertebral column (action: extension of the vertebral column) to improve activities of daily living involving with the use of the trunk movements.

Progressive muscle lengthening of the left external oblique muscle, which is situated on the lateral and anterior parts of the abdomen, towards side bending to the right (action: trunk rotation to the right, trunk flexion, side bending to the left) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the left external oblique muscle, which is situated on the lateral and anterior parts of the abdomen, towards trunk rotation to the left (action: trunk rotation to the right, trunk flexion, side bending to the left) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the left external oblique, which is situated on the lateral and anterior parts of the abdomen, towards trunk extension (action: trunk rotation to the right, trunk flexion, side bending to the left) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the right external oblique muscle, which is situated on the lateral and anterior parts of the abdomen, towards side bending to the left (action: trunk rotation to the left, trunk flexion, side bending to the right) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the right external oblique muscle, which is situated on the lateral and anterior parts of the abdomen, towards trunk rotation to the right (action: trunk rotation to the left, trunk flexion, side bending to the right) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the right external oblique, which is situated on the lateral and anterior parts of the abdomen, towards trunk extension (action: trunk rotation to the left, trunk flexion, side bending to the right) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the right internal oblique muscle also referred to as the same side rotators, towards trunk extension (action: compresses abdomen; rotate trunk to same side, flex the trunk, lateral trunk bending on same side) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the right internal oblique muscle also referred to as the same side rotators , towards trunk side bending to the left (action: compresses abdomen; rotate trunk to same side, flex the trunk, lateral trunk bending on same side) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the right internal oblique muscle also referred to as the same side rotators , towards trunk rotation the left (action: compresses abdomen; rotate trunk to same side, flex the trunk, lateral trunk bending on same side) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the left internal oblique muscle also referred to as the same side rotators , towards trunk extension (action: compresses abdomen; rotate trunk to same side, flex the trunk, lateral trunk bending on same side) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the left internal oblique muscle also referred to as the same side rotators , towards trunk side bending to the right (action: compresses abdomen; rotate trunk to same side, flex the trunk, lateral trunk bending on same side) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the left internal oblique muscle also referred to as the same side rotators , towards trunk rotation the right (action: compresses abdomen; rotate trunk to same side, flex the trunk, lateral trunk bending on same side) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the transverse abdominal muscle, the most important abdominal muscle for spinal stability, towards trunk extension (action: compress the abdominal contents to stabilize the spine) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the transverse abdominal muscle the innermost of the flat muscles of the abdomen, towards trunk extension (action: compress the abdominal contents to stabilize the spine) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the transverse abdominal muscle, which has fibers running horizontally from the side of the trunk to the front of the trunk, towards trunk extension (action: compress the abdominal contents to stabilize the spine) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the transverse abdominal muscle, the most important abdominal muscle for spinal stability, towards trunk extension (action: compresses the ribs and viscera, providing thoracic and pelvic stability) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the transverse abdominal muscle the innermost of the flat muscles of the abdomen, towards trunk extension (action: compresses the ribs and viscera, providing thoracic and pelvic stability) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the transverse abdominal muscle, which has fibers running horizontally from the side of the trunk to the front of the trunk, towards trunk extension (action: compresses the ribs and viscera, providing thoracic and pelvic stability) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the rectus abdominis muscle a paired muscle running vertically on each side of the anterior wall of the human abdomen , towards trunk extension (action: flexion of trunk/lumbar vertebrae) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the rectus abdominis muscle, which helps in keeping the internal organs intact by creating intra-abdominal pressure, towards trunk extension (action: flexion of trunk/lumbar vertebrae) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the rectus abdominis muscle, which is long, flat and extends along the whole length of the front of the abdomen , towards trunk extension (action: flexion of trunk/lumbar vertebrae) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the rectus abdominis muscles, which are two parallel muscles, separated by a midline band of connective tissue called the linea alba (white line), towards trunk extension (action: flexion of trunk/lumbar vertebrae) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the quadratus lumborum muscle, which connects the pelvis to the spine, towards contralateral side flexion of spine (action: unilateral action lateral flexion of vertebral column; acting bilaterally depression of thoracic rib cage) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the quadratus lumborum muscle , which is tight, short, and overused during prolonged sitting spine, towards contralateral side flexion of spine (action: unilateral action lateral flexion of vertebral column; acting bilaterally depression of thoracic rib cage) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the quadratus lumborum muscle towards contralateral side flexion of spine (action: unilateral action lateral flexion of vertebral column; acting bilaterally depression of thoracic rib cage) to improve activities of daily living involving with the use of the trunk movements. Progressive muscle lengthening of the quadratus lumborum muscle, which constantly contracts while seated , towards contralateral side flexion of spine (action: unilateral action lateral flexion of vertebral column; acting bilaterally depression of thoracic rib cage) to improve activities of daily living involving with the use of the trunk movements.

PRE

Progressive resistive exercise/ facilitation of the quadriceps, specifically the vastus medialis, which is important in stabilizing the patella and the knee joint during gait for an effective gait pattern.

Progressive resistive exercise/ facilitation of the knee extensors with emphasis of the rectus femurs to improve gait as it swings the leg forward into the ensuing step since it also acts also a flexor of the hip since it's attached to the ilium.

PRE LE

Progressive manual resistive exercise / facilitation of the psoas major towards flexion and external rotation in the hip joint to facilitate trunk balance when sitting and also to maintain the vertebral column upright to improve mobility involving with the use of the lower extremities.

Progressive resistive exercise (PRE)/ facilitation of the iliacus towards hip flexion to assist in lifting the trunk from a lying position and to improve mobility through the use of the lower extremities.

Progressive manual resistive exercise of / facilitation gluteus maximus towards external rotation and extension of the hip joint to help raise the trunk after stooping in unison with the hamstring muscles to improve mobility with the use of the lower extremities.

Progressive resistive exercise (PRE) / facilitation of the gluteus maximus the action of which is to cause the body to regain the erect position after stooping assisted in this action by the hamstring muscles to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE)/ facilitation of gluteus medius the main hip abductor preventing the opposite pelvis from dropping when standing on one leg towards hip abduction to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) / facilitation of the gluteus minimus a hip internal rotator and abductor primarily important in supporting the body on one leg towards abduction and internal rotation to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) / facilitation of the tensor fasciae latae towards thigh flexion, medial rotation and abduction facilitating stability of the pelvis on the head of the femur when standing to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) / facilitation of the quadratus femoris towards external rotation and adduction of thigh to stabilize the femoral head of the hip to its articulation with the acetabulum on the pelvis to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) of the inferior gemellus muscle towards external rotation of thigh to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) / facilitation of the piriformis towards hip external rotation to shift the body weight to the opposite side of the foot being lifted avoiding falls to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) / facilitation of the sartorius towards hip and knee flexion to facilitate donning and doffing of shoes.

Progressive resistive exercise (PRE) / facilitation of the sartorius towards hip and knee flexion to facilitate donning and doffing of socks to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) / facilitation of the sartorius towards hip and knee flexion to facilitate foot care and cutting of toe nails to improve activities of daily living involving with the use of the lower extremities. Progressive resistive exercise (PRE) / facilitation of the rectus femoris muscle towards hip flexion and knee extension which is crucial in the swing phase of gait to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) / facilitation of the vastus medialis muscle towards knee extension to prevent excessive lateral displacement of the patella to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) / facilitation of the vastus lateralis muscle which is the largest of the quadriceps femoris group of muscles towards knee extension to assist in sit to stand mobility and to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) / facilitation of the biceps femoris muscle towards hip extension and knee flexion necessary in lifting the buttocks of the bed in performing lower garment dressing while in bed and to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) / facilitation of the pectineus muscle towards hip flexion to facilitate ambulation and stair climbing activities to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) / facilitation of the pectineus muscle towards hip flexion to facilitate lower garment dressing activities and to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) of the pectineus muscle towards hip flexion to facilitate donning/doffing of shoes and socks to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) / facilitation of the obturator externus muscle towards hip adduction and external rotation necessary for dynamic stability while standing and to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) / facilitation of the gracilis muscle towards hip flexion and hip adduction to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) / facilitation of the adductor longus muscle of the thigh towards hip adduction to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) / facilitation of the adductor brevis muscle of the thigh towards hip adduction to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) / facilitation of the adductor magnus muscle of the thigh towards hip adduction to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) / facilitation of the adductor group of muscles of the thigh towards hip adduction to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) / facilitation of the tibialis anterior muscle towards dorsiflexion and inversion of the foot to facilitate heel strike during the contact phase of gait and to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) / facilitation of the tibialis anterior muscle towards dorsiflexion and inversion of the foot to keep the leg vertical even when walking on uneven ground and to to improve activities of daily living involving with the use of the lower extremities.

Progressive resistive exercise (PRE) / facilitation of the tibialis anterior muscle towards dorsiflexion and inversion of the foot necessary to allow the toes to clear the walking surface during the swing phase of gait.

Progressive resistive exercise (PRE) / facilitation of the triceps surae muscle towards plantarflexion of foot to facilitate ambulation during the push off phase of gait.

Progressive resistive exercise (PRE) / facilitation of the gastrocnemius muscle towards plantarflexion of the foot to facilitate ambulation during the push off phase of gait.

Progressive resistive exercise (PRE) / facilitation of the soleus muscle towards plantarflexion of the foot to facilitate ambulation during the push off phase of gait.

Progressive resistive exercise (PRE) / facilitation of the plantaris muscle towards knee flexion and plantarflexion of the foot to facilitate ambulation during the push off phase of gait.

Progressive resistive exercise (PRE) / facilitation of the peroneus longus muscle towards plantarflexion and eversion of the foot at the ankle joint to facilitate the loading response of foot during the contact phase of gait.

Progressive resistive exercise (PRE) / facilitation of the peroneus brevis muscle towards plantarflexion and eversion of the foot at the ankle joint to facilitate the loading response of foot during the contact phase of gait.

Progressive resistive exercise (PRE) of the peroneus longus muscle towards plantarflexion and eversion of the foot at the ankle joint to facilitate the foot flat phase during the contact cycle of gait.

Progressive resistive exercise (PRE) / facilitation of the peroneus brevis muscle towards plantarflexion and eversion of the foot at the ankle joint to facilitate the foot flat phase during the contact cycle of gait.

Progressive resistive exercise (PRE) / facilitation of the toe extensors towards toe extension to allow the toes to clear the walking surface during the swing phase of gait.

Progressive resistive exercise (PRE) / facilitation of the extensor hallucis brevis towards toe extension to allow the toes to clear the walking surface during the swing phase of gait.

Progressive resistive exercise (PRE) / facilitation of the extensor digitorum brevis towards toe extension to allow the toes to clear the walking surface during the swing phase of gait.

Progressive resistive exercise (PRE) / facilitation of the flexor digitorum brevis towards flexion of second to fifth toes to facilitate easier donning of shoe.

Progressive resistive exercise (PRE) / facilitation of the toe flexor muscles located on the plantar surface of the foot towards toe flexion to facilitate donning of shoes/footwear.

PRE Torso

Progressive Resistive Exercise (PRE) / facilitation of the splenius capitis towards cervical extension, rotation, and laterally flexion which is essential in cervical motions to improve activities of daily living involving with the use of the neck.

Progressive Resistive Exercise (PRE) / facilitation of the splenius cervices towards ipsilateral rotation and lateral flexion of the neck to improve pull of the head posteriorly to improve activities of daily living involving with the use of the neck.

Progressive resistive exercise (PRE) / facilitation of the left external oblique towards trunk flexion and rotation to the right to facilitate dynamic and static balance

Progressive resistive exercise (PRE) / facilitation of the right external oblique towards trunk rotation to the left to facilitate dynamic and static balance.

Progressive resistive exercise (PRE) / facilitation of the left internal oblique towards trunk flexion and rotation to the left to improve dynamic and static balance to improve activities of daily living involving with the use of the trunk flexion and rotation.

Progressive resistive exercise (PRE) of the right internal oblique towards trunk flexion and rotation to the right to improve dynamic and static balance and to improve activities of daily living involving with the use of the trunk flexion and rotation

Progressive resistive exercise (PRE) / facilitation of the transverse abdominal muscle towards abdominal compression by drawing the belly button towards the spine (vacuum exercise) to improve the stability of the vertebral column to improve activities of daily living involving with the use of the trunk movements.

Progressive resistive exercise (PRE) / facilitation of the transverse abdominal muscle towards abdominal compression by drawing the belly button towards the spine (drawing in maneuver) to improve the stability of the vertebral column to improve activities of daily living involving with the use of the trunk movements.

Progressive resistive exercise (PRE) / facilitation of the rectus abdominis muscle towards trunk flexion to improve posture column to improve activities of daily living involving with the use of the trunk movements.

Progressive resistive exercise (PRE) / facilitation of the quadratus lumborum muscle towards lateral flexion of vertebral column (hip hiking) to reduce the risk of unilateral low back pain and column to improve activities of daily living involving with the use of the trunk movements.

Progressive resistive exercise (PRE) of the levator ani muscles to address urinary incontinence. Progressive resistive exercise (PRE) of the pubococcygeus muscle by making it contract similar to stopping the flow of urine when emptying bladder (Kegel exercises - to be performed when bladder is empty) Progressive resistive exercise (PRE) of the pubococcygenus muscle by performing the Kegel exercises to address urinary incontinence. Progressive resistive exercise (PRE) of the puborectalis muscle by performing pelvic floor muscular contractions similar to when inhibiting defecation crucial to addressing bowel incontinence. Progressive resistive exercise (PRE) of puborectalis muscle by performing pelvic floor muscular contractions similar to when controlling defecation crucial to addressing bowel incontinence. Progressive resistive exercise (PRE) of the coccygeus muscle by performing pelvic floor muscular contractions similar to when inhibiting defecation crucial to addressing bowel incontinence. Progressive resistive exercise (PRE) of coccygeus muscle by performing pelvic floor muscular contractions similar to when controlling defecation crucial to addressing bowel incontinence.

STM

STM LE

Soft tissue mobilization performed with focus on the psoas major area approximately from the transverse processes, bodies and discs of T12-L5 towards the lesser trochanter of the femur to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the iliacus approximately from the iliac fossa towards the lesser trochanter of femur to improve activities of daily living involving with the use of the lower extremities.

Soft tissue mobilization performed with focus on the gluteus maximus from the gluteal surface of ilium, lumbar fascia, sacrum, sacrotuberous ligament towards the the gluteal tuberosity of the femur and iliotibial tract to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the gluteus medius approximately from the gluteal surface of ilium, under gluteus maximus towards the greater trochanter of the femur to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the tensor fasciae latae approximately from the iliac crest towards the iliotibial tract. Soft tissue mobilization performed with focus on the quadratus femoris from the area on top of the Ischial tuberosity towards the intertrochanteric crest to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the superior gemellus approximately from the spine of the ischium towards the obturator internus tendon to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the inferior gemellus approximately from the ischial tuberosity towards the obturator internus tendon to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the piriformis approximately from the sacrum towards the greater trochanter of the femur to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the sartorius approximately from the anterior superior iliac spine a bony prominence in the pelvis towards the pes anserinus on the anteromedial aspect of the tibia to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the rectus femoris muscle approximately from the area surrounding the ilium on the pelvis towards the tibial tuberosity of the tibia to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the quadriceps femoris muscle approximately from the ilium and shaft of the femur towards the tibial tuberosity on the tibia to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the biceps femoris muscle approximately from the ischial tuberosity of the pelvis towards the head of the fibula and lateral tibial condyle to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the semitendinosus muscle approximately from the ischial tuberosity of the pelvis towards the pes anserinus on the tibia to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the pectineus muscle approximately from the superior pubic ramus towards the lesser trochanter and linea aspera of the femur to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the obturator externus muscle approximately from the obturator foramen and obturatory membrane towards the greater trochanter of the femur to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the gracilis muscle approximately from the ischiopubic ramus towards the pes anserinus on the tibia to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the adductor magnus approximately from the pubis of the pelvis towards the femur and tibia to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the adductor longus approximately from the pubis of the pelvis towards the femur and tibia to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the adductor brevis approximately from the pubis of the pelvis towards the femur and tibia to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the tibialis anterior muscles approximately from the body of the tibia towards the medial cuneiform and first metatarsal bones of the foot to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the triceps surae muscle approximately from the end of the femur and upper part of the tibia posteriorly towards the calcaneus of the foot via the Achilles tendon. Soft tissue mobilization performed with focus on the gastrocnemius muscle approximately from the medial and lateral condyle of the femur posteriorly towards the calcaneus of the foot via the Achilles tendon to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the soleus muscle approximately at the upper part of the tibia posteriorly towards the calcaneus of the foot via the Achilles tendon to improve activities of daily living involving with the use of the lower extremities.

Soft tissue mobilization performed with focus on the plantaris muscle approximately from the top of the lateral supracondylar ridge of femur above the lateral head of gastrocnemius towards the tendo calcaneus (medial side, deep to gastrocnemius tendon) on the foot to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the popliteus muscle approximately from the lateral femoral condyle towards the posterior tibia under the tibial condyles to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the peroneus longus muscle approximately from the side of the fibula towards the first metatarsal, medial cuneiform on the foot to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the toe extensors towards approximately from the top of the calcaneus towards the phalanx of the great toe and proximal dorsal region of middle phalanges 2, 3 & 4 to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the flexor digitorum brevis approximately from the calcaneus at the bottom side of the foot towards the phalanges of toes 2 to 5 to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the flexor hallucis brevis approximately from the bottom of the foot on the cuboid bone towards the medial and lateral sesamoid bones of first metatarsal of the foot to improve activities of daily living involving with the use of the lower extremities. Soft tissue mobilization performed with focus on the muscles of the plantar surface of the foot from their origin approximately from the heel and tarsals towards the phalanges of the toes to improve activities of daily living involving with the use of the lower extremities.

STM Torso Soft tissue mobilization performed to the splenius capitis approximately from the ligamentum nuchae and spinous process of C7-T6 towards its insertion: mastoid process of temporal and occipital bone to improve activities of daily living involving with the use of the trunk musculature. Soft tissue mobilization performed to the splenius cervices approximately from the spinous processes of vertebrae T3 or T4 to T6 intervening supraspinous ligaments towards the posterior tubercles on the transverse processes of cervical vertebrae C1 to C3 or C4 to improve activities of daily living involving with the use of the trunk musculature. Soft tissue mobilization performed with focus on the left external oblique approximately from the top of the left lower eight ribs towards the iliac crest and inguinal ligament to improve activities of daily living involving with the use of the trunk musculature. Soft tissue mobilization performed with focus on the right external oblique approximately from the top of the right lower eight ribs towards the iliac crest and inguinal ligament to improve activities of daily living involving with the use of the trunk musculature. Soft tissue mobilization performed with focus on the left internal oblique approximately from the thoracolumbar fascia, anterior two-thirds of the iliac crest, and lateral half of the inguinal ligament towards the inferior border of the 10-12th ribs, linea alba, and the pubis via the conjoint tendon to improve activities of daily living involving with the use of the trunk musculature. Soft tissue mobilization performed with focus on the right internal oblique approximately from the thoracolumbar fascia, anterior two-thirds of the iliac crest, and lateral half of the inguinal ligament towards the inferior border of the 10-12th ribs, linea alba, and the pubis via the conjoint tendon to improve activities of daily living involving with the use of the trunk musculature. Soft tissue mobilization performed with focus on the transverse abdominal muscle approximately from the iliac crest, inguinal ligament, lumbar fascia, and cartilages of inferior six ribs towards the xiphiod process, linea alba, and pubis (pelvis) to improve activities of daily living involving with the use of the trunk musculature. Soft tissue mobilization performed with focus on the rectus abdominis muscle approximately from the pubis a part of the pelvis towards the costal cartilage of ribs 5 to 7, and xiphoid process of sternum to improve activities of daily living involving with the use of the trunk musculature. Soft tissue mobilization performed with focus on the quadratus lumborum muscle approximately from the top on the iliac crest and iliolumbar ligament towards the last rib and transverse processes of lumbar vertebrae to improve activities of daily living involving with the use of the trunk musculature.

HEP

thoracic

§ Progressed home exercise program to dynamic breathing exercise x 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - cervical / thoracic exercise x 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to thoracic manual range of motion - Spine Progressed home exercise program to extension exercise x 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to thoracic manual range of motion - spine extension exercise x 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to thoracic lengthening - extension / pectoral lengthening exercise x 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to thoracic manual range of motion - side lengthening exercise x 6 seconds hold x 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to thoracic manual range of motion - rotation exercise x 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to thoracic lengthening exercise x 7secs hold, 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to thoracic manual range of motion - side bends exercise x 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to thoracic lengthening - supine extension exercise x 7 secs. Hold x 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to thoracic lengthening - vertebral exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to thoracic muscle strengthening - latissimus (tubing row) exercise x 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to thoracic muscle strengthening- triceps / latissimus (tubing pull for extension) exercise x 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to thoracic muscle lengthening - lateral shoulder exercise x 5-10 repetitions for 2 sets, 2-3 times daily § thoracic Care Tips Muscle o back § Progressed home exercise program to muscle lengthening / flexion - gluteals / low back exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening / flexion - gluteals / low back exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - abdominals exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - abdominals / gluteals exercise x 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - abdominals / shoulder (lumbar stabilization) exercise x 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - abdominals / shoulder (flexion) exercise x 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - abdominals / thigh muscles (Lower extremity - flexion) exercise x 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - Mobilization - low back extension exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to extension - prone relaxation exercise x 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to manual range of motion / muscle lengthening - back extension exercise x 7 secs hold x 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening / strengthening - back extension manual range of motion - low back extension exercise x 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening- low back extension exercise x 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - lumbar / hip exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - Sacroiliac exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - Sidelying lumbar exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - piriformis exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily

o knee § Progressed home exercise program to knee extension / muscle strengthening - quadriceps exercise x hold 8 repetitions for 2 sets, 2 times daily § Progressed home exercise program to knee flexion / muscle strengthening - quadriceps exercise x 5-10 repetitions for 2 sets, 2 times daily § Progressed home exercise program to knee manual range of motion - knee muscle lengthening exercise x 10 repetitions for 2 sets, 3 times daily § Progressed home exercise program to knee manual range of motion - prone knee muscle lengthening exercise x 10 repetitions for 2 sets, 3 times daily § Progressed home exercise program to knee muscle strengthening - hamstrings (prone heel-to-Buttocks lengthening) exercise x 8 repetitions for 2 sets, 2 times daily § Progressed home exercise program to knee muscle strengthening- hip flexion / quadriceps exercise x 8 repetitions for 2 sets 2 times daily § Progressed home exercise program to knee muscle strengthening - quadriceps exercise x 10 repetitions for 2 sets 2 times daily § Progressed home exercise program to knee muscle strengthening - hip adduction (isometric) exercise x 5-10 repetitions for 2 sets, daily § Progressed home exercise program to knee muscle strengthening - quadriceps exercise x 7secs. hold 7 repetitions for 2 sets, 2 times daily § Progressed home exercise program to knee muscle lengthening - quadriceps exercise x 7secs. hold 6 repetitions for 2 sets, 2 times daily § Progressed home exercise program to knee muscle lengthening - hamstring exercise x 7secs. hold 6 repetitions for 2 sets, 3 times daily § Progressed home exercise program to knee muscle strengthening - hamstring exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to knee partial squat vastus medialis oblique (VMO) muscle exercise x 12repetitions for 2 sets, 3 times daily § Progressed home exercise program to knee pillow squeeze on vastus medialis Oblique (VMO) exercise x 7secs. hold 5repetitions for 1 set, 3 times daily § Progressed home exercise program to knee manual range of motion - heel prop exercise x 10 repetitions for 2 sets, 2 times daily § knee Care Tips o Total knee § Progressed home exercise program to manual range of motion - ankle § Progressed home exercise program to knee muscle strengthening - quadriceps (isometric) exercise § Progressed home exercise program to knee muscle strengthening - hamstrings (isometric) exercise § Progressed home exercise program to Progressed home exercise program to knee muscle strengthening - quadriceps with hip flexion exercise § Progressed home exercise program to knee muscle strengthening - quadriceps with hip flexion exercise § Progressed home exercise program to manual range of motion - knee exercise § Progressed home exercise program to knee muscle lengthening - hamstrings exercise § Progressed home exercise program to manual range of motion - knee flexion exercise § Progressed home exercise program to knee muscle strengthening - hamstrings with knee flexion exercise § Progressed home exercise program to knee strengthening - hamstrings / gluteals with hip / knee flexion exercise § Progressed home exercise program to knee muscle strengthening - quadriceps with hip flexion exercise § Progressed home exercise program to muscle strengthening - hip abduction exercise § Progressed home exercise program to strengthening- hip adduction exercise § Progressed home exercise program to knee muscle strengthening - quadriceps exercise § Progressed home exercise program to Range of Motion exercise § Progressed home exercise program to knee manual range of motion - sitting knee flexion exercise § Progressed home exercise program to knee manual range of motion - sitting knee flexion exercise § Progressed home exercise program to knee manual range of motion - sitting knee flexion exercise o hip § Progressed home exercise program to hip muscle lengthening - gluteals / low back exercise x 7secs. hold 6 repetitions for 1 sets, 2-3 times daily § Progressed home exercise program to hip muscle lengthening - piriformis / hip external rotation exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to hip muscle lengthening - hip adduction exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to hip manual range of motion - hip Internal / external rotation exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to hip muscle lengthening / manual range of motion exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to hip manual range of motion / muscle lengthening - trunk rotation exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to manual range of motion / muscle lengthening - hip exercise § Progressed home exercise program to hip muscle strengthening - gluteals exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to hip muscle strengthening - hip abduction exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to hip muscle strengthening - hip Progressed home exercise program to flexion exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to hip muscle lengthening - hip flexion exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to hip muscle strengthening - gastrocnemius exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to hip Long Axis Distraction (Passive) exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to hip muscle lengthening - Iliotibial Band exercise (supine) exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to hip muscle lengthening - Iliotibial Band standing exercise § Progressed home exercise program to hip/pelvic bridging level 1 (Pelvic lifts)exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to hip/pelvic bridging level 2 Pelvic Lifts with hold) exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to hip/pelvic bridging level 3 (Pelvic Lifts with sway) exercise pelvic bridging x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to hip/pelvic bridging level 4 (Pelvic lifts with Bobath tech at 180 deg) exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to hip/pelvic bridging level 5 (more decreased angle of knees) exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to hip/pelvic bridging level 6 (Stronger LE in FABER position on top of weaker side) exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to hip/pelvic bridging level 7 (Stronger LE crossed on top of the weaker side) exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to hip/pelvic bridging level 8 exercise Stronger LE in SLR position x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § hip Care Tips o Total hip § Progressed home exercise program to muscle strengthening - quadriceps exercise § Progressed home exercise program to muscle strengthening - gluteals exercise § Progressed home exercise program to strengthening - quadriceps exercise § Progressed home exercise program to manual range of motion - ankle exercise § Progressed home exercise program to Range of Motion exercise § Progressed home exercise program to Progressed home exercise program to muscle lengthening / manual range of motion exercise § Progressed home exercise program to muscle strengthening - abduction exercise § Progressed home exercise program to muscle strengthening - Internal / external rotation exercise § Progressed home exercise program to manual range of motion - shoulder exercise § Progressed home exercise program to muscle strengthening - biceps / triceps exercise § Progressed home exercise program to muscle strengthening - finger flexion exercise § Progressed home exercise program to muscle strengthening - triceps / quadriceps exercise § Progressed home exercise program to muscle strengthening - abduction exercise § Progressed home exercise program to muscle strengthening - gluteals exercise § Progressed home exercise program to muscle strengthening - hamstrings with knee flexion exercise § Progressed home exercise program to muscle strengthening - hip flexion exercise § Progressed home exercise program to Progressed home exercise program to muscle strengthening- hip abduction exercise § Progressed home exercise program to muscle strengthening - gluteals exercise o ankle / foot § Progressed home exercise program to Amanual range of motion - Toe flexion exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to Amanual range of motion - Interossei exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to Pmanual range of motion (lengthening) - Toe flexion / extension (Passive) exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to Amanual range of motion - ankle dorsi / plantar flexion exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to Amanual range of motion - ankle Inversion / Eversion (Side Bends) exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to Amanual range of motion - ankle Inversion / Eversion & dorsi / plantar flexion (Circumduction) exercise § Progressed home exercise program to muscle strengthening - ankle plantar / dorsiflexion exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - Intrinsics (muscles of Arch) exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - ankle Inversion / Eversion exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - plantar Fascia exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - Soleus exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - gastrocnemius exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - dorsiflexion exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - Eversion (isometric) exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - Eversion (Resistive) exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - Inversion (Resistive) exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - plantar flexion (Resistive) exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - dorsiflexion (Resistive) exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - inversion (isometric) exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § · Mobility o sitting § Progressed home exercise program to muscle strengthening - hamstrings / quadriceps exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - gluteals / Adductors exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - triceps / gluteals exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - lateral trunk exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - quadriceps exercise § Progressed home exercise program to muscle strengthening - hip flexion exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - lumbar extension exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - Suboccipital (Axial extension) exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - upper trapezius exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to manual range of motion - Shoulders exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - dorsi / plantar flexion exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily

o sitting to standing § breathing exercise § Progressed home exercise program to manual range of motion - trunk exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - hip extension exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - triceps exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - quadriceps exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - Toe extension / manual range of motion - plantar flexion exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to manual range of motion - trunk exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - shoulder x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily o o Gait § Progressed home exercise program to muscle strengthening - ankle dorsi / plantar flexion exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - gastrocnemius exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - hip flexion / extension exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - hip abduction exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - hip extension exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to manual range of motion - hip flexion / extension & abduction / adduction exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to manual range of motion / lengthening - hip Internal / external rotation & low back rotation exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - ankle dorsi / plantar flexion exercise § Progressed home exercise program to proprioception/ kinesthetic activities exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to proprioception / Kinesthetic Activities/ coordination exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to Big Stepping without swaying exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - hip adduction & innternal rotation exercise § Progressed home exercise program to proprioception/ kinesthetic activities - trunk Weight Shift exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to Arm Swings exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to knee straighteners exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily

o balance § Progressed home exercise program to manual range of motion / lengthening - low back / gluteals exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to abductionominals / back extension exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - ankle dorsi / plantar flexion exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § muscle lengthening - gastrocnemius exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to proprioception/Kinesthetic Activities - One-Legged Stands exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to proprioception/ kinesthetic activities - One-Legged Stands Eyes Closed exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to proprioception/Kinesthetic Activities- Toe Stands exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to proprioception/ kinesthetic activities - heel Stands exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to proprioception/ kinesthetic activities - Head Tilts exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to proprioception/ kinesthetic activities - Head Tilts Up and Down x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to proprioception/ kinesthetic activities - Two-Legged standing rotation exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to proprioception/ kinesthetic activities - Head Motion exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to proprioception/ kinesthetic activities - Eye Motion exercise § Progressed home exercise program to proprioception/ kinesthetic activities - Grapevine exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to proprioception/ kinesthetic activities - High Stepping exercise § Progressed home exercise program to Walking Head Turns exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to Walking Figure Eights exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to Semi Tandem standing exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to Tandem standing exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to balance / proprioception / kinesthetic activities exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - thigh / leg musculature exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - low back / abductionominals exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § o Flexibility § Progressed home exercise program to muscle lengthening - cervical extension / flexion exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - cervical Side Bends / flexion exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § M Progressed home exercise program to muscle lengthening - trapezius exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - levator shoulder x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - shoulder flexion / extension exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - trunk Side Bends exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - thoracic rotation exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - cervical / thoracic extension exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - hamstring / low back extension exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - gluteals exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - thoracic / lumbar exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - hamstring / low back extension exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - hip flexion exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - gastrocnemius x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - shoulder extension exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to Amanual range of motion / lengthening - ankle muscles exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - low back / thoracic / cervical exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - hip / low back rotation exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - Full Body exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - hamstring exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - piriformis / gluteals exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily

o Posture § Progressed home exercise program to muscle lengthening - cervical exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to manual range of motion - cervical exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to manual range of motion - cervical exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - upper trapezius exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - Scapular protraction / retraction exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - Scapular protraction / retraction exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - rhomboid exercise progressed home exercise program to muscle lengthening - trunk exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - abdominals exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle lengthening - lumbar exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - gluteals exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to manual range of motion - shoulder exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to proprioception / strengthening- plantar flexion exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - back extension exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - Scapular retractionor exercise

o breathing § Quick Test § Deep Effective Breaths exercise § lengthening - shoulder Girdle Intercostals exercise § shoulder protraction / retraction exercise § Heavyweight breathing exercise § Posture Awareness § Pursed Lip breathing exercise § breathing Tips o strengthening Regimen § Progressed home exercise program to muscle strengthening - biceps brachii exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - triceps brachii exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - anterior deltoids / biceps exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - finger flexion exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - pectorals / triceps exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - abductionominals exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - quadriceps exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - quadriceps/gluteals x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - gastrocnemius exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening - abductionominals exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening- Pubococcygeus muscle exercise x 7secs. hold 5-10 repetitions for 2 sets, 2-3 times daily § Progressed home exercise program to muscle strengthening Training Tips · Special Conditions o Osteoporosis § Progressed home exercise program to muscle strengthening - thoracic / lumbar extension exercise § Progressed home exercise program to muscle strengthening - rhomboid exercise § Progressed home exercise program to muscle lengthening - Suboccipital (Axial extension) exercise § M Progressed home exercise program to uscle lengthening - shoulder retraction exercise § Progressed home exercise program to muscle lengthening - shoulder flexion exercise § muscle lengthening - thoracic / lumbar extension exercise § Progressed home exercise program to muscle strengthening - gluteals (isometric) exercise § Progressed home exercise program to muscle strengthening - quadriceps exercise § Progressed home exercise program to muscle strengthening – gastrocnemius exercise § Progressed home exercise program to muscle lengthening - Gastrocnemius-Soleus exercise § Progressed home exercise program to muscle strengthening - triceps exercise § Progressed home exercise program to muscle lengthening - Corner exercise § Progressed home exercise program to muscle lengthening - Body Extender (Arms Down) exercise § Progressed home exercise program to muscle strengthening - trunk / lateral shoulder muscles & pectorals exercise § Progressed home exercise program to muscle strengthening - trunk /forearm / shoulder muscles exercise o Arthritis § Deep breathing § Amanual range of motion - Suboccipital muscles (Axial extension) exercise § Amanual range of motion - cervical muscles exercise § Amanual range of motion - upper trapezius / rhomboid / levator / scapulae / mid trapezius exercise § Amanual range of motion - finger flexion & extension exercise § Amanual range of motion - wrist flexion & extension exercise § Amanual range of motion - forearm supination & pronation exercise § Amanual range of motion - biceps (elbow flexion) exercise § Amanual range of motion - shoulder flexion (deltoids & biceps) exercise § Amanual range of motion - shoulder Horizontal abductionuctors / retractionors exercise § Amanual range of motion - spinal Side Bender muscles exercise § Amanual range of motion - spinal rotation exercise § Amanual range of motion - spinal extension exercise § Amanual range of motion / strengthening - quadriceps exercise § manual range of motion / strengthening - hip abduction / adduction exercise § muscle strengthening - gluteals exercise § Amanual range of motion - ankle dorsi / plantar flexion exercise § Amanual range of motion - Toe flexion exercise o Lower extremity Amputee § Amanual range of motion - trunk extension exercise § Amanual range of motion - quadriceps extension exercise § hip flexion (Active / Resistant) exercise § trunk extension (isometric) § muscle strengthening - abductionominals (isometric) exercise § muscle strengthening - hip extension (isometric) exercise § muscle strengthening - hip adduction (isometric) exercise § muscle strengthening - hip adduction (isometric) exercise § muscle strengthening - gluteals (isometric) exercise § muscle lengthening / strengthening - Full Body (isometric) exercise § muscle strengthening - gluteals exercise § muscle strengthening - gluteals / abductionominals exercise § manual range of motion - hip abduction exercise § muscle lengthening - hip flexion exercise o Parkinson § Deep breathing § muscle lengthening - suboccipital (Axial extension) exercise § manual range of motion - knee / ankle / foot exercise § muscle lengthening - lumbar / hip exercise § manual range of motion - hip / knee / ankle exercise § muscle strengthening - hip flexion § muscle strengthening- dorsiflexion § balance / proprioception - The Grapevine exercise § standing Rocks exercise § standing Side Rocks exercise § manual range of motion - trunk exercise § manual range of motion - hand / wrist exercise § manual range of motion - finger opposition § manual range of motion - cervical exercise § strengthening- upper trapezius exercise § Face exercises § anterior Pelvic Tilt (supine) § strengthening- gluteals / quads / trunk / triceps § Postural strengthening § manual range of motion - trunk (supine) o Stroke § muscle strengthening - hip / knee flexion exercise § muscle strengthening - rhomboid / pectorals exercise § muscle strengthening - lateral cervical flexion exercise § balance / proprioception exercise § muscle strengthening- quadriceps exercise § manual range of motion - ankle exercise § muscle strengthening - gluteals (isometric) exercise § muscle strengthening - quadriceps exercise § manual range of motion - hip adduction exercise § sitting Weight Shift exercise § muscle strengthening - quadriceps exercise § muscle strengthening - quadriceps / gluteals exercise § muscle strengthening - hip abduction exercise § manual range of motion - upper extremity Reach exercise § manual range of motion - supine Reach exercise § manual range of motion - supine Reach (Advanced) exercise § manual range of motion - Scapulo-Humeral (standing) exercise § Weight Bearing hand Sit exercise § muscle strengthening - Scapular Stabilateralizer exercise § muscle strengthening - Scapular Stabilateralizer (Advanced) exercise § muscle strengthening - wrist extension exercise § Muscular (Movement) coordination exercise § muscle strengthening- forearm supination / pronation exercise § Arm Movements (Supported) exercise § Weight Shift - Involved Side exercise § Weight Shift - Forward upper Body: scapulae exercise § Weight Shift - Forward upper Body exercise § Weight Shift - Forward upper Body(Advanced) exercise § Muscular (Movement) coordination - Lower extremity exercise

§ Geriatrics exercises § 1. AAmanual range of motion elbow flexion w/cane (cane assist biceps curl) § 2. AAmanual range of motion hip hike unilateral stand w/elastic (Elastic assist hip hike) § 3. AAmanual range of motion hip/knee flexion (heel slides) w/person (Caregiver heel slides) § 4. AAmanual range of motion shoulder ER bilateral supine w/cane abduction (cane assist overhead twist) § 5. AAmanual range of motion shoulder ER bilateral supine w/cane neutral (cane assist arm out) § 6. AAmanual range of motion shoulder IR w/cane (cane assist behind back lift) § 7. Amanual range of motion alt arms supine hooklying (Hooklying alternating front raises) § 8. Amanual range of motion ankle DF bilateral stand (Toe raise) § 9. Amanual range of motion ankle DF/PF (not elevationated) (ankle pump) § 10. Amanual range of motion ankle PF bilateral stand (Double heel raise) § 11. Amanual range of motion cervical retraction (chin tuck) supine (supine chin tuck) § 12. Amanual range of motion cervical rot supine (supine neck turn) § 13. Amanual range of motion cervical sidebending supine (supine neck sidebend) § 14. Amanual range of motion elbow ext stand (triceps kickbacks) (standing triceps kickback) § 15. Amanual range of motion elbow flexion/ext (biceps curl) § 16. Amanual range of motion elbow flexion/ext (arms abduction) in Pool (Pool scarecrow) § 17. Amanual range of motion Face cheek elevation (Cheek squeeze) § 18. Amanual range of motion Face forehead elevation (Eyebrow raise) § 19. Amanual range of motion Face grimace (Grimace) § 20. Amanual range of motion Face mouth/lip compression (Purse lip) § 21. Amanual range of motion Face neck depression (Platysma) (Platysma drill) § 22. Amanual range of motion finger walk (finger walk) § 23. Amanual range of motion gait crossovers (Crossovers) § 24. Amanual range of motion gait toe to toe walk (heel toe walk) § 25. Amanual range of motion gait walking (Walking) § 26. Amanual range of motion hand cane balance (cane balance) § 27. Amanual range of motion hip abduction bilateral supine (Leg angels) § 28. Amanual range of motion hip abduction unilateral sidelying w/person (eccentrics) (Leg raise eccentrics) § 29. Amanual range of motion hip abduction unilateral stand (Side leg kickout) § 30. Amanual range of motion hip abduction unilateral supine (supine side leg) § 31. Amanual range of motion hip ER sit (sitting leg in) § 32. Amanual range of motion hip ER/IR supine bilateral (supine double hip rotations) § 33. Amanual range of motion hip ext prone knee bent (Bent knee kickback) § 34. Amanual range of motion hip ext prone straight leg (prone leg raise) § 35. Amanual range of motion hip ext stand knee straight (Straight leg mule kick) § 36. Amanual range of motion hip flexion (sitting SLR) (sitting SLR) § 37. Amanual range of motion hip flexion (SLR) supine knee bent (Straight leg raise) § 38. Amanual range of motion hip flexion alt on Ball (Ball marching) § 39. Amanual range of motion hip flexion alt sit (Seated march) § 40. Amanual range of motion hip flexion sit (Seated knee lift) § 41. Amanual range of motion hip flexion stand bent knee (Chair march) § 42. Amanual range of motion hip hike supine (supine hip hike) § 43. Amanual range of motion hip hike unilateral stand (hip hike) § 44. Amanual range of motion hip marching (Seated marching) § 45. Amanual range of motion hip marching on Ball (Marching on ball) § 46. Amanual range of motion hip marching w/ alt arms (Seated leg/arm marching) § 47. Amanual range of motion hip marching w/alt arms on Ball (Marching arm salute on ball) § 48. Amanual range of motion hip/knee flexion (heel slides) (heel slides) § 49. Amanual range of motion hip/knee stance unilateral (clock reach) (Clock reach) § 50. Amanual range of motion knee ext (long arc quads) sit (Long arc) § 51. Amanual range of motion knee ext (short arc quads) sit (short arc) § 52. Amanual range of motion knee flexion prone (prone ham curl) § 53. Amanual range of motion knee flexion sit to stand (Sit to stand) § 54. Amanual range of motion knee marching (standing high step) § 55. Amanual range of motion knee partial lunge (short lunge) § 56. Amanual range of motion knee wall slide bilateral partial (Partial wall slide) § 57. Amanual range of motion kneel, half kneel, stand (kneel to half kneel to stand) § 58. Amanual range of motion lumbar alt leg/arm (bird dog) (Bird dog) § 59. Amanual range of motion lumbar bridging bilateral (bridging) § 60. Amanual range of motion lumbar bridging unilateral (Single leg bridge) § 61. Amanual range of motion lumbar ext prone (elbow press ups) (prone elbow press up) § 62. Amanual range of motion lumbar ext prone low level (prone back extend) § 63. Amanual range of motion lumbar ext quadruped (cat) (Cat) § 64. Amanual range of motion lumbar ext standing (standing back extension) § 65. Amanual range of motion lumbar flexion bilateral knee to chest (Double knee to chest (DKC)) § 66. Amanual range of motion lumbar flexion bilateral knee to chest hooklying (Single knee to chest hooklying) § 67. Amanual range of motion lumbar flexion quadruped (camel) (kneeling camel) § 68. Amanual range of motion lumbar flexion unilateral knee to chest (Single knee to chest (SKC)) § 69. Amanual range of motion lumbar lying prone arms up (prone prop up on pillow) § 70. Amanual range of motion lumbar rotation sit (sitting trunk twist) § 71. Amanual range of motion lumbar rotation supine (supine knee side to side) § 72. Amanual range of motion lumbar side to side sit on Ball (sitting side tilt on ball) § 73. Amanual range of motion lumbar side bend pushup (Side bend push up) § 74. Amanual range of motion shoulder abduction (finger walking) at wall (shoulder finger side walk up) § 75. Amanual range of motion shoulder abduction/adduction (cradle rock) (Cradle rock) § 76. Amanual range of motion shoulder abduction/adduction overhead w/cane (Overhead cane side to side) § 77. Amanual range of motion shoulder circles (choo-choo) (Choo choo) § 78. Amanual range of motion shoulder circles supine w/cane (cane circles) § 79. Amanual range of motion shoulder circum bilateral (Arm circles) § 80. Amanual range of motion shoulder elevation/retraction bilateral (shoulder rolls) (shoulder rollbacks) § 81. Amanual range of motion shoulder flexion (finger walking) at wall (Forward arm wall walk) § 82. Amanual range of motion shoulder flexion bilateral w/cane (cane double front arm raise) § 83. Amanual range of motion shoulder flexion bilateral w/cane (shoulder press) (cane overhead press) § 84. Amanual range of motion shoulder horizontal abduction/adduction stand w/cane (Front cane side reach) § 85. Amanual range of motion shoulder horizontal abduction/adduction supine w/cane (cane dance) § 86. Amanual range of motion shoulder IR w/cane (Behind back cane lift) § 87. Amanual range of motion shoulder ladductioner (shoulder ladductioner) § 88. Amanual range of motion shoulder overhead press bilateral (Double overhead press) § 89. Amanual range of motion shoulder pendulum (shoulder pendulum) § 90. Amanual range of motion shoulder press up bilateral w/cane (cane press up) § 91. Amanual range of motion shoulder retraction bilateral stand hands at neck (Open fly stretch) § 92. Amanual range of motion shoulder retraction/thoracic ext - Sun Salute (Sun salute) § 93. Amanual range of motion shoulder retraction ion w/cane (cane backward lift) § 94. Amanual range of motion shoulder touches (shoulder touches) § 95. Amanual range of motion shoulder/wrist rotation bilateral stand w/cane (cane shoulder twist) § 96. Amanual range of motion shoulder/wrist rotation bilateral supine w/cane (cane twister) § 97. Amanual range of motion thoracic breathing overhead arms supine (Overhead arm breath) § 98. Amanual range of motion thoracic diaphragm breathing (Reclined diaphragm breathing) § 99. Amanual range of motion thoracic ext supine (mid back arch) § 100. Amanual range of motion thoracic mid chest expansion (mid chest breathing) § 101. Amanual range of motion thoracic rotation diag (Seated trunk diagonal) § 102. Amanual range of motion thoracic rotation w/cane (sitting trunk twist with dowel) § 103. Amanual range of motion thoracic sidebend (sitting side bend) § 104. Amanual range of motion thoracic upper chest expansion (upper chest breathing) § 105. Amanual range of motion thumb CMC circum (thumb circles) § 106. Amanual range of motion thumb/finger opposition (thumb to finger touch) § 107. Amanual range of motion toe intrinsics (Toe intrinsics) § 108. Amanual range of motion trunk flexion supine w/ball (Static abdominal crunch w/ball) § 109. Amanual range of motion vestib standing balance (dynamic) (Feet together standing balance) § 110. Amanual range of motion vestib standing balance w/stride (standing stride balance) § 111. Amanual range of motion wrist circles (wrist circles) § 112. Amanual range of motion wrist sup/pron (wrist twist) § 113. Grav- shoulder protract/retraction (Seated shoulder punch) § 114. Grav- wrist flexion/ext (wrist side to side) § 115. Iso ankle DF (isometric supine foot lift) § 116. Iso cervical flexion (isometric forward neck push) § 117. Iso cervical rotation (isometric neck twist push) § 118. Iso cervical sidebend (isometric side neck push) § 119. Iso hip abduction sit w/belt (isometric hip out) § 120. Iso hip adduction sit w/pillow (Seated leg squeeze) § 121. Iso hip gluteal sets (prone glut set) § 122. Iso hip gluteal sets supine (supine glut sets) § 123. Mob thoracic ext (Wall angel) § 124. Mob thoracic sidebend/rot/ext sit (sitting thoracic extend and twist) § 125. Pmanual range of motion ankle circum w/person (Caregiver ankle circles) § 126. Pmanual range of motion ankle inv/ever w/person (Caregiver passive ankle side to side) § 127. Pmanual range of motion hip IR/ER w/flexed leg w/person (Caregiver flexed hip rotations) § 128. Pmanual range of motion hip IR/ER w/straight leg w/person (Caregiver hip rotations) § 129. Pmanual range of motion hip/knee flexion (heel slides) w/person (Caregiver passive heel slides) § 130. Pmanual range of motion shoulder abduction w/person (Caregiver passive side arm lift) § 131. Pmanual range of motion shoulder adduction w/person (Caregiver passive arm across) § 132. Pmanual range of motion shoulder ext w/person (Caregiver passive arm pull back) § 133. Pmanual range of motion shoulder flexion w/person (Caregiver passive arm lift) § 134. Pmanual range of motion shoulder horizontal adduction w/person (Caregiver passive arm crossover) § 135. Pmanual range of motion shoulder IR/ER w/person (Caregiver arm rotation) § 136. Resist ankle DF w/elastic (Elastic ankle pull up) § 137. Resist ankle ever bilateral w/elastic (Elastic double ankle pull out) § 138. Resist ankle inv w/elastic (Elastic ankle pull in) § 139. Resist ankle PF unilateral w/ elastic (Tubing gas pedal) § 140. Resist Diaphragmatic breathing w/wt. (Weighted abdominal lift) § 141. Resist finger flexion grip w/putty (Putty finger squeeze) § 142. Resist finger flexion intrinsics w/putty (Putty fingertip squeeze) § 143. Resist finger intrinsics w/putty (Putty taffy pull) § 144. Resist hand gross opposition w/putty (Putty finger grab) § 145. Resist hand key pinch w/putty (Putty key pinch) § 146. Resist hand three jaw chuck pinch w/putty (Putty three jaw chuck) § 147. Resist hip flexion (sitting SLR) w/wt (Weight seated SLR) § 148. Resist hip flexion sit w/elastic (Elastic march) § 149. Resist hip/knee flexion (heel slides) supine w/elastic (Elastic supine heel slide) § 150. Resist knee bike upright (Upright bike) § 151. Resist knee press w/elastic (Elastic seated leg press) § 152. Resist knee w/Recumbent Stepper (Recumbent stepper) § 153. Resist lumbar ext sit w/elastic (Elastic sitting lean back) § 154. Resist lumbar ext stand w/elastic (Elastic back pull back) § 155. Resist lumbar flexion sit w/elastic (Elastic sitting crunch) § 156. Resist lumbar rotation supine w/elastic (supine elastic back twist) § 157. Resist lumbar sidebend w/elastic (Elastic trunk sidebend) § 158. Resist lumbar sidebend w/wt (DB trunk sidebend) § 159. Resist shoulder diagonal D1 ext w/elastic (Elastic shoulder diagonal down and out) § 160. Resist shoulder diagonal D1 flexion w/elastic (Elastic shoulder inward crossover) § 161. Resist shoulder diagonal D2 ext w/elastic (Elastic shoulder diagonal down and in) § 162. Resist shoulder diagonal D2 flexion w/elastic (Elastic diagonal up and out) § 163. Resist shoulder elevation/retraction bilateral w/elastic (shoulder rolls) (Elstic shoulder shrugs) § 164. Resist shoulder ER bilateral w/elastic (Tubing double outward arm) § 165. Resist shoulder flexion bilateral w/elastic (Elastic double front arm raise) § 166. Resist shoulder horizontal abduction bilateral w/elastic (Elastic reverse flies) § 167. Resist shoulder overhead press bilateral w/wt (DB double overhead press) § 168. Resist stance heel/toe w/crosspull w/elastic (heel toe elastic pull) § 169. Resist stance unilateral w/crosspull w/elastic (One leg balance with elastic) § 170. lengthening finger flexors (finger table stretch) § 171. lengthening Gastroc sit w/person (Caregiver calf stretch) § 172. lengthening Gastroc sit w/towel (sitting Gastroc towel stretch) § 173. lengthening Gastroc unilateral standing (Runner stretch) § 174. lengthening hamstring sit w/person (Caregiver hamstring stretch) § 175. lengthening hamstrings supine active (Kick up hamstring stretch) § 176. lengthening hamstrings supine w/towel (Towel hamstring stretch) § 177. lengthening hip adductionuctor stand w/chair (Inside leg chair stretch) § 178. lengthening hip flexors leg abduction supine (Off table hip stretch) § 179. lengthening lumbar rotation supine w/person (Caregiver trunk twist) § 180. lengthening Pectoral standing bilateral at door (Pectoral door stretch) § 181. lengthening Pectoral standing unilateral (Side Pectoral stretch) § 182. lengthening quads sit (sitting Quad stretch) § 183. lengthening quads standing (standing Quad stretch) § 184. lengthening rhomboids/trapezius (sitting rhomboid stretch) § 185. lengthening shoulder blade pinch supine (anterior chest stretch) § 186. lengthening shoulder flexion at wall (Arm up shoulder wall stretch)

Allen's Cognitive level

Allen's Cognitive Levels

Level I (Automatic Actions) Conscious to the external environmental is minimal. characterized by automatic motor responses and changes in the autonoic nervous system.

Level II (Postural Actions) PROP cues. Poor imitation of posture. unable to imitate the running stitch, three stitches.

Level III (Manual Actions) Repetitive Training. Recognize family & friends. Able to complete basic self-care tasks if VERBAL reminders are provided. Sanding. Follow simple directions: "Squeeze my hands" or "Look at me." Able to imitate the running stitch, three stitches.

Level IV (Goal-Directed Actions) VISUAL cues. Can carry out established routines but cannot cope w/ unexpected events. Matching colors of clothing, step by step illustrated directions, engage in simple activities (self-feeding and dressings), learn new skills by imitating a model or demonstration. Provide project samples for clients to dublicate. Able to imitate the whipstitch, three stitches.

Level V (Exploratory Actions) Understand cause and effect. New learning occurs. Overt trial and error problem solving. Can performa a task involving 3 familiar steps and a new one, plan a 3 course meal. Able to imitate the single cordovan using overt trial and error methods, three stitches.

Level VI (Planned Actions) SYMBOLIC cues. Can do mental trial and error problem solving. 30 mins of attention spane, aware of month, time, & year, ADL with min A, ability to recognize errors, written directions for the clients to follow. Able to imitate the single cordovan stich using covert trial and error methods, three stitches.

Cognitive movement strategies

Sitting down

>approach the chair with firm steps, at good pace; • make a wide turn in front of the chair and stop straight in front of the chair: you must have the feeling that you walk around something (first, practice this, for example, with a cone in front of the chair, later without the cone); if necessary, turn at the rhythm of the cue you already used when you were approaching the chair; • place your calf or back of the knee against the seat; • bend slightly forward and bend through the knees, keep your weight well above your feet; • move with your hands towards the arms of the chair or the seat, seek for support with your arms; • lower yourself in a controlled manner; sit down well, at the back of the chair.

Rise from a chair

• place your hands on the arms or the side of the seat; • move your feet towards the chair (just in front of the chair legs, two fists apart); • shift your hips to the edge of the chair; • bend your trunk (not too far, nose above the knees); • rise gently, from your legs, let your hands lean on the arms of the chair, the seat or your thighs, and then extend your trunk completely (if necessary, make use of a visual cue). In case of starting problems rock back and forth a few times and rise at the third count.

Stand up after a fall

Rest after the fall • turn from lying, through side-sit (pushing up the trunk with hetero-lateral arm and homo-lateral elbow support), to the position on hands and knees; • crawl to an object to pull yourself up (for example chair, bed); • bend the strongest leg and place the opposite arm on the object (rifleman’s position); • push yourself up with legs and arms.

Getting in bed

It is advisable to slide the covers to the foot of the bed first (like an accordion); the top of the cover points in the direction of the head of the bed, so it can be pulled easily over the patient. For aids and other provisions (for instance, a bed adjustable in height) the working group refers to an occupa- tional therapist. 84 V-19/2004 KNGF Guidelines for physical therapy in patients with Parkinson’s disease

Strategy 1

• approach the bed with firm steps, possibly with the use of a rhythmical cue , and make a wide turn in front of the bed (not over one leg), and walk at a good pace until you feel the bedside with your calf or back of your knee; • sit down on the edge of the bed (be sure there is enough distance to the pillow); • lower the upper part of the body in the direction of the pillow, and place the weight on the elbow; • lift the legs one by one into the bed so that you are lying on your side; • grab the covers with your free arm; • lower the upper part of the body onto the mattress and try to lie comfortably by moving your backside; • pull the covers over the body.

Strategy 2

• approach the bed forwards with firm steps, if necessary make use of a rhythmical cue; • bend forward, lean with your hands on the mattress and crawl onto it in such a way that you are positioned on your knees, lengthwise, at the middle of the mattress; • lie down on your side (be sure there is enough distance to your pillow); • grab the covers with your free arm and pull them over your body.

Strategy 3

• approach the bed forwards with firm steps, if necessary make use of a rhythmical cue, make a wide turn in front of the bed (not over one leg), and walk at good pace until you feel the bedside with your calf or back of your knee; • sit down on the bed, with sufficient distance and in diagonal direction to the pillow, with the arms as back- ward support; • place your legs, one by one, on the mattress, turn until you are lengthwise on the mattress; • grab the covers at the end of the bed, slide your feet under the covers; • lower yourself quietly until you are lying on your back, hold on to the covers and pull them over your body.

Turning in bed, from a position on the back

Smooth sheets (satin) or satin pyjamas make sliding or turning easier. Socks can give more grip on the sheets and, with that, make turning easier.

Strategy 1 (through head/shoulders)

• move the cover to the side opposite to the one you want to turn to; • lift the cover with your arms and pull up your knees while you are lying on your back, put your feet flat on the bed; • move your body to the side, alternating with your feet, your pelvis, and your head and shoulders, in the opposite direction of the turn; • place your arm which is on the side you want to turn to next to your head, then turn your head and shoul- ders, use your free arm for the direction; • then lower your knees in the direction of the turn, if possible make some room under the covers with your free arm; • lie down comfortably.

Strategy 2 (through legs/pelvis)

• move the cover to the side opposite to the one you want to turn to; • lift the cover with your arms and pull up your knees while you are lying on your back, put your feet flat on the bed; • move yourself to the edge of the bed (alternating with your feet, pelvis, head and shoulders), in the opposite direction of the turn; • place your arm which is on the side you want to turn to next to your head; • pull up your knees as far as you can (in the direction of your chest, your feet on the mattress) and ‘drop’ in the direction of the turn (if necessary lift the cover with your free arm), roll over with your pelvis; • head and shoulders follow the free arm; • lie down comfortably.

Strategy 3 (through arm swing)

• lift the cover and pull up your knees, while you are lying on your back, and put your feet flat on the bed; • move yourself to the edge of the bed (alternating with your feet, pelvis, head and shoulders), in the opposite direction of the turn; • outstretch one or two arms vertically; • bend your knees or keep your legs straight, whatever you prefer; • make a rolling movement with your total body, using an arm swing; • lie down comfortably.

N.B. For all three strategies it is important that the patient does not roll off the bed and lies in the middle of the mattress. Getting out of bed: from lying on the back to sitting on the edge of the bed The following tips might make it easier to get out of bed: • at night a nightlight is on to make visual feedback possible. • on the bed are no light covers or smooth sheets. • the patient wears smooth (satin) pyjamas and socks for more grip. • the bed is not too low. • handy aids are: elevator to lift a patient, sliding board, handles on the sides of the bed (occupational thera- pist).

Strategy 1

• move your body a bit from the middle to the edge of the bed. • roll over on your side (see turning in bed); • pull your knees further to your chest; • open the cover; • place your top arm next to your bottom shoulder; • bring your feet over the edge of the bed and, at the same time push yourself up with both arms (if help- ful, support sitting up with your bottom arm straight and the hand of your other arm placed nearby your elbow).

Strategy 2

• bend your knees, put your feet flat on the bed; • move yourself to the edge of the bed (alternating with your pelvis, shoulders and feet), in the opposite direc- tion of the turn; • lift the covers; • shift your feet over the edge of the bed and, at the same time roll over to your side; • place the hand your top arm on the bed near the elbow of your other arm; • bring your feet over the edge of the bed and, at the same time push yourself up with both arms (if helpful, support coming to sit with your bottom arm straight and the hand of your other arm placed nearby your elbow). From sitting on the edge of the bed to standing

Strategy

• sit upright on your buttocks; • lean on your arms, place your fists a bit behind your body; • shift your buttocks to the edge of the bed; • lean with your arms on the edge of the bed; • place your feet right in front of the bed, approximately 20 cm apart; • bend forward (with your nose above your knees); • stand up from your legs, if necessary rock first.

PSYCH

Patient has anosognosia with lack of awareness or insights of hi/hers deficits
presents impulsivity
difficulty assimilating and accommodating new information, while still managing to retain old information
peripheral inattention (focus on central field when communicating): early stages of many dementias, reduced processing of peripheral visual information is part of the brain’s effort to eliminate all but the most important incoming data due to lack of ability to process at the same level and speed previously used. Because visual data is vital to engagement and interaction, it is common for people in early stages of dementia to lose ‘edge awareness’ vision as there is a need to focus on the central field of vision.
Taking something others belonging. It is likely that the patient’s combination of reduced pre-frontal cortex ability to over-ride commands and the excitability of his right amygdala have led him to believe he ‘needs’ and must have the "cake" with no consideration of the other person’s perspective.
masks confusion with anger
delayed processing direction
lack of insights into deficits
low frustration tolerance
easily distracted
short attention span
poor sustained attention
does not pay attention to instructions
fails to maintain attention
forgetfulness
easily distracted
poor judgment
difficulty concentrating
loss of immediate recall
word finding difficulty
Word salad- using hairbrush for toothbrush (agnosia)
sequencing difficulty
Visuospatial skills deficit (how objects relate to one another)
does not remain on task
poor train of thought
poor cognition process
poor planning and organization
does not pay attention to details
does not follow instructions
poor memory recall
apathy, impassivity, dispassion
uninterestedness
excessive uneasiness and apprehension
compulsive behavior
aggravation
restlessness
depression with severe despondency and dejection
Markedly diminished interest or pleasure in almost all activities
Impaired concentration
indecisiveness
Difficulty concentrating, remembering details, and making decisions
Feelings of guilt, worthlessness, and/or helplessness
persistent sad, anxious, or "empty" feelings
aggressive and belligerent
poor remembering sequences in directions or instructions despite written reminders
Patient has poor mental abilities and mental processes related to attention, short- term memory & working memory (structures and processes used for temporarily storing and manipulating information) , judgement , reasoning, problem solving & decision making, comprehension & production of language.
Emotional disturbance and/or behavioural problems include: aggressive or anti-social behaviour; inattentiveness; distractibility and impulsiveness; impaired social interactions; inability to cope with the routine of daily tasks; attention-seeking behaviours such as negative interactions or a poor attitude towards treatment; depressed behaviours such as withdrawal, anxiety and mood swings. Emotional disturbance and/or behavioral problems, frequently off-task that adversely affect the learning; shows aggression towards others and refuse to co-operate.

Dementia is a neurocognitive disorders. Neurocognitive disorders are acquired conditions with underlying brain pathology that result in a decline in learning, memory, planning, decision-making, and performing routine tasks. With progression of the disease, additional neurological symptoms, such as agnosia, apraxia, or aphasia, are seen.
Dementia is loss of cognitive functioning: thinking, reasoning and remembering.
Alzheimer’s disease: Most common type, primary symptom is short-term memory loss, visuospatial deficits, apraxia, preserved motor fxn in early stage, individuals can live 20 years after diagnosis, presence of plaques fragments of beta amyloid and TAU tangles
Lewy body dementia: Closely related to Parkinson’s disease (if motor deficits appear first, if cognitive first- Lewy body dementia), Primary symptoms include REM sleep behavior disorder, visual hallucinations, and fluctuations in alertness and attention
Vascular dementia: Most common with PMHx of CVAs and TIAs, symptoms reflect area of infarcts
Frontotemporal dementia: two subtypes: Behavioral variant (BvFTD), Changes in behavior and personality, Primary progressive aphasia (PPA), Language deficits appear first- Bruce Willis
Stages of Dementia

Global Deterioration Scale (GDS) – Stage 1: Normal cognition – Stage 2: Age-associated memory impairment – Stage 3: Mild cognitive impairment – Stage 4: Mild dementia—caregiver does 25% – Stage 5: Moderate dementia—caregiver does 50%, Can no longer survive without assistance – Stage 6: Moderately severe dementia—caregiver does 75% – Stage 7: Severe dementia—caregiver does 100

Stages of Dementia

- Preclinical: changes in the brain begin years before a person shows any signs of the disease. This time period is called preclinical Alzheimer's disease and it can last for years. - Mild, Early Stage: symptoms at this stage include mild forgetfulness but person may still live independently at this stage, but increased trouble with remembering a name, recalling recent events, remembering where he or she put a valuable object, making plans, staying organized, managing money. - Moderate, Middle Stage: at this stage, symptoms include increasing trouble remembering events, problems learning new things, trouble with planning complicated events (like a dinner), trouble remembering their own name and personal history, problems with reading, writing, and working with numbers, now that some people are familiar but not remember their names, lose track of time and place, need help choosing the right clothing and getting dressed, become moody or withdrawn, Be restless, agitated, anxious, or tearful, Physical changes may occur as well, Choosing the right clothing for the weather - Severe, Late Stage: lose many physical abilities, may lose bowel and bladder control, may be able to say some words or phrases, needs help with all activities, is unaware of recent experiences and of his or her surroundings, is more likely to get infections

Signs of Alzheimer’s disease: Poor judgement or decision-making, Inability to manage a budget, Losing track of the date or season, Misplacing things and not having the ability to retrace steps to find them
Typical age-related changes: Making a bad decision once in a while, Missing a monthly payment, Forgetting which day it is and remembering later, Difficulty having a conversation Sometimes forgetting a word to use, Losing things from time to time
Communication strategies: gain attention (say the name, gentle touch, communicate in eye level), speak simply (less figurative language and pronoun usage), speak slowly (increase latency by adding pauses), show more and speak less, /person centered care (supported participation and engagement, emphasize personal relevance and contextual training like targeting functional reach by having them clean the windows of their bedroom), avoid confrontation, validation technique (do not refute, reiterate what he/she said and acknowledge, do not refute then redirect)

Dementia Intervention

Behavioral Strategies:

Utilize one-step command
Keep eye contact
Speak at eye level
Talk slowly
Use 3 words statement to communicate (take a bath, brush your teeth)
Use gesture
One instructions at a time
Do not approach from behind
Be calm, show sincerity
Compliment the patient
Do Not Rush (Slow down)
Use positive statements
"Back off" and ask permission
Reassure patient
Offer guided choices between two options
Offer simple exercise options
Try to limit stimulation
Utilize low tone voice
Provide positive feedback
Redirect as needed
Try to accommodate the behavior, not control the behavior
Do not Make sudden movements
Do not Show alarm or offense
Do not Demand, force or confront
Do not Argue
Monitor personal comfort (check for pain, hunger, thirst, constipation, full bladder, fatigue, infections and skin irritation)
Maintain a comfortable room temperature
Don’t argue about the facts (their reality is different)
Avoid being confrontational or arguing about facts. For example, if a person expresses a wish to go visit a parent who died years ago, don't point out that the parent is dead. Instead, say, "Your mother is a wonderful person. I would like to see her too."
Redirect the person's attention. Try to remain flexible, patient and supportive by responding to the emotion, not the behavior.
Create a calm environment. Avoid noise, glare, insecure space and too much background distraction, including television.
Allow adequate rest between stimulating events (Allow rest during active times)
Provide a security object (give an object of comfort to hold: purse or handkerchief)
Acknowledge requests, and respond to them.
Look for reasons behind each behavior
Check for personal comfort
Redirect the person’s attention (stuck on happy)
- INTERVENTIONS:

Interventions include: empathy approach with active listening, compassionate presence, affirmation, encouragement and reassurance with patient

redirection (when the going gets tough, distract and redirect)
Patient required supplementation of written instructions with verbal explanations and oral instructions.
Instructional tasks were broken down into small segments to improve participation.
Presentation of information and new concepts at a slow rate to allow for an adequate amount of time for auditory and visual processing with avoidance in abstract language when delivering instructions.
Emphasis of instructions and feedback of information with the use of visualization to chunk the information into categories for recall.
Patient requires continual structure and routine as necessary components to create an atmosphere conducive to task completion.
Instructions were presented in multi-modal stepwise manner, presented both visually and verbally, to provide necessary accommodations to overcome memory impairment.
The use of memory strategies of key words, visualization, and chunking of instructions was quite helpful.
Patient requires extra time to process and complete instructions but responded with simple, answerable questions. Patient participated with the treatment and responded with affection and reassurance approach.
Patient responded with a positive mood approach for interaction. Utilized body language to communicate thoughts more strongly than words and set a positive mood by speaking in a pleasant and respectful manner. In addition, facial expressions, low tone of voice, and physical touch to help convey instructions were utilized with positive results.
Patient responded with simple words and sentences. Therapist spoke slowly, distinctly, and in a reassuring tone; refrained from raising voice higher and utilized low tone voice. Patient responded with 90 seconds rule before asking another question.

From approximately six feet away, smile, bring your hand up near your face and say “Hi, Greet.” When your presence has been acknowledged, offer your hand by walking toward him with an extended offer to handshake. Shake hands while moving your body into a side non-confrontational supportive stance and remain at arm’s length. Then while either sitting or getting down to his eye level, say your name...USE visual, verbal, touch cuing sequence. The use of public, personal, and intimate space awareness and boundaries is optimal when initiating interaction with someone in mid-stage dementia.
Use Positive Physical Approach (PPA), then stand to the side and stay at arm’s length for the session. Explanation: Using this approach you will likely establish a positive connection, but you may still have difficulty following thru with treatment goals. Creating a physical interaction where you are at the same eye level will set you up for better visual and verbal communication.
Use PPA to connect, then remaining to the side at arm’s length, ask if you can sit on the edge of his bed. Keeping your body close to him in a side supportive position use hand under hand technique as you work together on a few tasks. Explanation: This is a good way to create an environmentally supportive set-up. Using PPA along with visual-verbal-touch cueing is typically very effective for someone with dementia. Using hand-under-hand throughout the interaction will keep both of you safe while working on tasks.
Knock on the door frame and use PPA to get connected to the man at arm’s length. Offer a visual cue by pointing to the bedside commode saying, “May I?” Then gesture that you want to move the commode over to the person’s side, in the place where you are standing. Explanation: his approach and process is the best option. Given the situation, it provides the most effective way to manage the environment and attempt treatment goals.

DC Plan

DISCHARGE PLANNING & CASE MANAGEMENT

Discharge Date:

Physical Therapy Long Term Goals: Patient is expected to attain all long term goals in the currently established plan of care.

Discharge Location: home with____

DME: has standard cane, 2WW, FWW, wheelchair; facilitated order for:

Home Exercise Program: Initiated home exercise program: (quad sets, hamstring sets, ankle slides, gluteal sets, short arc quads, long arc straight leg raises, ankle pumps, sitting knee extension, sitting knee flexion, standing hip extension, heel raises, standing knee flexion, standing knee raises, toe raises, standing hip abduction/adduction, mini squats with % accuracy.

Caregiver Training and Education: Patient’s family member/caregiver was notified regarding the availability of the therapist for caregiver instructions and how further services will be accessed. Patient’s family was notified and offered to attend physical therapy session for caregiver instruct/training.

Continuum of Care: Patient will be discharged from subacute rehabilitation with recommendation to avail home health physical therapy. Patient/caregiver was educated that physical therapy can be provided in the patient's place of residence to ensure that the patient outcomes are optimal. Assisted the patient/family in locating and coordinating post-discharge services.

Coordination of Care: Coordinated with OT (), social worker () for appropriate discharge planning and to ensure that the patient’s needs will be met after discharge from the facility.

[1] ttp://www.mediware.com/rehabilitation/tools/item/g-code-conversion-calculator

[2] ttp://www.mccc.edu/~behrensb/documents/210wk4TherapeuticExercise_000.pdf

[3] ttp://www.eldergym.com/fall-prevention-in-the-elderly.html

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