Dual Tasking Treatments for Occupational Therapy

The patient engaged in a rhythmic recall and repeat activity requiring the processing of a clapping rhythm requiring dynamic BUE engagement while seated presented by the therapist. The rhythms varied between 6-10 beats/movements for a total 15 reps. The patient demonstrated 4/15 rhythms accurately with greater difficulty noticed beyond 6 movements/beats per rep. Due to the nature of the patient's dx and the decreasing ability to perform movement during a cognitive-demanding activity, this task is purposed to encourage neuronal activation in the basal ganglionic center / Putamen which is said to assist an individual in the registration and interpretation of rhythmic phenomenon required to maintain internal rhythm as well as internal rhythm used for essential activities of life including respiration, ambulation, and the performance of activities requiring BUE and BLE mobility while thinking.

Patient participated in a skilled intervention to increase participation in feeding and other fine motors daily living tasks. Throughout retrieval and placement activity, the patient was tasked with modulation of hand, wrist, and finger movement to maintain efficient spoon placement, the pacing of self, attention to the task at hand, awareness and response to change in the placement of container, intentional focus on muscle movement and blocked repetition of activity has potential to establish new neural pathways to increase participation and carryover in feeding task. Activity simulated necessary feeding skills required and, overall, the patient demonstrated success in compensatory spoon holding technique; the patient engaged in the activity for 10 consecutive minutes.

The patient engaged in theraputty activity routine using 'soft' resistance to address fine motor deficits and intrinsic muscle weakness resulting in a decreased ability to participate in essential acts requiring prehension, coordination, and fine motor skills like patient defined occupations of writing and meal preperation. The patient was required to do 10 reps of each exercise including finger scissor, the finger spread, fingertip pinch, flat pinch, power grip, finger extension, and full grip. The patient engaged in a therapist-initiated 30s-60s rest between each exercise to prevent muscle fatigue. No c/o pain or discomfort noted.

The patient engaged in a kinetic-based therapeutic activity requiring the gathering of 10-15 coins (60 coins in total) alternating BUE with subsequent placement of each coin into a resistive coin bank. The task elicited fine motor coordination, in-hand manipulation, and muscle endurance of intrinsic muscles of the hand. Task requires translation, shift, rotation and stabilization of the objects within the palm space by eliciting mm involvement of the ring and pinky fingers while isolating movement of the coins with the thumb, index and middle fingers. The patient verbalized complaints of cramping and fatigue towards the end of the activity but was intrinsically motivated to complete the task. The patient was observed to drop approx 6 beads out of 60 throughout the activity due to fatigue.

The patient engaged in a fine motor activity using the right hand (left hand to assist prn) to retrieve coin using thumb abduction and/or tip pinch, maintain grip and place into a slightly resistive target. The patient was very challenged by this activity requiring frequent adaptations. The patient was unable to retrieve independently requiring max ax1/and placement of coin in web space of thumb x10 coins. The activity seeks to elicit fine motor active range of motion, coordination, pinch strength, translation, and skills of prehension.

The patient engaged in a kinetic-based therapeutic activity requiring the gathering of 20 beads into the palm of the right hand (and then left in separate repetition) with subsequent placement of each bead into a small target. The task elicited fine motor coordination, in-hand manipulation, and mm endurance of intrinsic muscles of the hand. Task requires translation, shift, rotation, and stabilization of the objects within the palm space by eliciting mm involvement of the ring and pinky fingers while isolating movement of the beads with the thumb, index, and middle fingers.

The patient engaged in Baoding balls 2 x 2-minute intervals in the left hand to promote intrinsic muscle strength, stability, and control of radiocarpal joint. The activity is designed to promote muscle isolation, manipulation, passive tendon glides, and muscle stamina/endurance of the left hand to promote engagement in functional activities requiring object manipulation using prehension.

The patient engaged in a seated fine motor activity requiring the patient to use alternating tip pinch, 3 point pinch, and lateral pinch prehension skills to secure clips [varying levels of resistance] to small objects 25x with the right hand in order to increase intrinsic hand strength, thumb strength, pinch strength, fine motor coordination, and general pain-free mobility. Good challenge. Fatigue noted and observe by end of the task. No discomfort noted.

The patient engaged in a BUE AROM, mm Elongation, and generalized strengthening activity requiring him to hold the hula hoop at various points to elicit gross shoulder flexion, pronation/supination, internal/external rotation, scapular protraction/retraction. The patient performs 2x15 for each movement pattern with noted fatigue at the end of the sequence. Therapeutic rest offered.

The patient engaged in edge of seat dynamic activity using a balloon to elicit alternating RUE nad LUE engagement with unsupported trunk x50 repetitions to increase postural control, core stability, righting reaction during bed mobility, bathing, and dressing at edge of bed.

The patient engaged in seated concentric isotonic contraction during bilateral shoulder flexion with sustained isometric hold at volitional end range (less than 20 degrees). The patient used a weightless baton to promote elements of EBP bilateral training. COTA/s present during session providing proprioceptive feedback and physical cue for compensatory movements of neck and trunk lateral flexion.

The patient engaged in edge of seat dynamic activity holding a weightless bar with BUE requiring the batting of a balloon 2x25 times to elicit simultaneous BUE engagement. Patient also required to hold bar with one hand while batting balloon in many visual fields to encourage eye-hand coordination, sustained attention to activity, forsight and intuitive reasoning, and increase postural control, core stability, and righting reactions during bed mobility, bathing and dressing at edge of bed. The patient required demonstration by wife and therapist in order to initiate task x2 before mimicking kinetic therapeutic activity.

The patient engaged in a BUE AROM, mm Elongation, and generalized strengthening activity requiring him to hold the hula hoop at various points to elicit gross shoulder flexion, pronation/supination, internal/external rotation, scapular protraction/retraction. The patient performs 2x15 for each movement pattern with noted fatigue at the end of the sequence. Therapeutic rest offered.

Patient engaged in functional reach activity while seated using cans found in pantry approximately 1lb each requiring BUE and core isometric muscle contraction while reaching beyond BOS x12 inches with CGA (2x10 reps) in order to promote muscle strengthening, enhanced posture, diaphragmatic breathing, and endurance for an activity to produce increased safety during bed mobility, functional transfers/ambulation, participation in ADLs/IADLs, and the prevention of falls with a possibility of subsequent injury.

Patient engaged in an unsupported seated dynamic balance training utilizing balance disk and engaging in alternating lateral trunk flexion repetitions with the return to midline (10/10 each side) and alternating BUE punches crossing the midline (15/15 each side) to challenge and strengthen trunk and back musculature, initiate controlled movement, maintain postural alignment and COG over BOS, excite neural pathways when moving in diagonal patterns and crossing midline, and strengthen BUE to support increase patient's ability to use chairs without armrests at home and community without fear of falling.

Patient engaged in functional reach activity requiring BUE and core/trunk isometric muscle contraction while reaching to ground level with proper body mechanics, touching target (colored cone), and returning to standing posture with CGA (2x10 reps) in order to promote muscle strengthening, vestibular conditioning, enhanced posture, diaphragmatic breathing, and endurance for activity. Because the patient has a noted history of falls due to picking up items from floor-level, activity used to increase safety and ability pick up items efficiently and confidently while decreasing risk for fall.

Patient engaged in functional reach activity while standing using cans found in pantry approximately 1lb each requiring BUE and core isometric muscle contraction while reaching beyond BOS x12 inches with CGA (2x10 reps) in order to promote muscle strengthening, enhanced posture, diaphragmatic breathing, and endurance for an activity to produce increased safety during bed mobility, functional transfers/ambulation, participation in ADLs/IADLs, and the prevention of falls with a possibility of subsequent injury.

The patient engaged in a catch/release task with medium-sized lightweight ball in variable transfer styles including bouncing and throwing at multiple heights while simultaneously alternating counts every other digit until 100. This task was used to increase postural support, reaction time, neuromuscular communication, simultaneous motor unit recruitment in BUE, and establishment of stron BOS, ability to right COG over BOS, and the ability to perform dual-task activities requiring the performance of executive functions and mobility-based tasks. The patient required multiple verbal cues to ensure directions were correct and increased in confidence throughout the task. The patient displayed no difficulties in manipulating numbers nor did she experience LOB.

The patient engaged in a standing balance activity requiring anticipatory postural movements to adapt to BLE placement on dome of a BOSU Ball. Activity used to improve motor calibration and coordination as well as amplify abilities of weight-shift, ankle joint stability and ability to adapt to ever changing center of gravity. The patient remained on BOSU throughout isometric activity 3x 2 minute sets with CGA and a chair placed anterior to patient for increased confidence. The patient was not observed to experience LOB, and defined activity as a good challenge. He required rest break after each set and was noted to exerpience increasing BLE mm fatigue with each set. .

The patient engaged in a dynamic balance activity requiring BLE placement on a BOSU Ball requiring good balance, good weight-shift, ankle stability, coordination, and control. The patient was required to maintain COG over BOS while reaching upward and crossing midline to retrieve yellow theraband. WOnce yellow theraband secured in grasp, the patient was required to shift his gaze posteriorly, return forward, and complete cross-midline resistance training. 10 reps each arm while alternating BUE to promote cross-midline intersection. The patient was not observed to experience LOB, and defined activity as a good challenge. The patient requires Good + dynamic balance with reaction time and coordination during simultaneous BUE activity in order to return to work post-injury.

The patient participated in a 15-minute exercise using a hurdle to simulate objects found within home/community mobility in order to utilize and enhance joint-stability and movement absorption, agility, eye-foot coordination, executive functioning to follow a multi-step command, neuromuscular communication, depth perception, reaction time, directional orientation (R, L, B, F), motor praxis, and strength. The patient was able to follow a 1 step command 8/10 times and a 2 step command 6/10 with CGA for balance and safety.

The patient engaged in a dynamic standing activity requiring unilateral LE balance over 1 second while performing a toe-tapping activity to reach the target for the purpose of increasing BLE modulation and eye-foot coordination during functional mobility activities. The patient was not able to perform greater than 1 second unilateral LE stance demonstrating atypical weight-shift, but was noted to complete the task successfully using rhythmic coordination of metronome at 60 BPM. The patient required moderate education and verbal cueing for auditory processing and motor praxis.

The patient engaged in a seated fine motor activity requiring the patient to use alternating tip pinch, 3 point pinch, and lateral pinch prehension skills to secure clips [varying levels of resistance] to small objects 25x with the right hand in order to increase intrinsic hand strength, thumb strength, pinch strength, fine motor coordination, and general pain-free mobility. Good challenge. Fatigue noted and observe by end of the task. No discomfort noted.

The patient engaged in dynamic standing activity requiring the propulsion of weighted balls [ 16oz, 18oz, 20oz] from 8ft away to a pitchback altering between objects for recognition and enhancement of modulation ability. The task was performed 2x25 reps while alternating between right and left extremity enhancing BUE strength and range of motion, forearm strength, functional grasp/intrinsic strength, reaction time, force absorption through palm and wrist joint, balance, postural alignment, gross muscle stamina, and endurance for activity. 3 sets of 2x25 were performed while standing on various platforms including an unstable balance pad and rockerboard. The patient was able to achieve this activity but displayed signs and symptoms of fatigue throughout progression. Therapeutic rest offered between each step to prevent muscle fatigue and episodes of imbalance.

The patient engaged in an activity requiring him to stand on balance pad [uneven surface] with BLE to evoke balance and right reaction while reaching upward and crossing midline to retrieve yellow theraband. Once yellow theraband secured in grasp, the patient was required to shift his gaze posteriorly, return to forward, and complete cross-midline resistance training. 10 reps on each side. This task is used to improve the patient's ability to maintain balance while reaching up into cupboards which he identified to be a challenge for him.

The patient was offered education provided regarding scar management and massage. Encouraged patient to massage scar up and down, side to side and making small circles with light pressure to decrease the risk of adhesions.

The patient engaged in a dynamic obstacle course requiring him to carry a tray of drinks in one hand and a 4lb bag in the other hand while traversing an obstacle course designed to elicit agility by performing a figure-8 pattern through cones placed 12 inches apart, BLE strength by ascending/descending stairs, and visual perceptual skills and BLE motor modulation through cleaning 8/8 hurdles. The patient was successful in 8/8 graded repetitions and demonstrated increasing confidence throughout each repetition as evidenced by the ability to begin just holding a drink and grading up to drinks + bag + an increase in stair rise.

The patient engaged in 15 consecutive minutes of kicking a soccer ball around a large room recruiting cardiovascular and pulmonary efficiency, gross motor coordination, eye-foot coordination, reaction time, visual perceptual and acuity skills, attention to task, gross strength, and executive functioning. The patient demonstrated adequate ability to maintain aerobic activity without complaints of fatigue, weakness, or SOB.

The patient engaged in an unsupported standing dynamic activity requiring the ability to bounce a large exercise ball back forth across room 50x without a self-initiated break in order to increase postural control, core stability, dynamic standing balance, the establishment of strong BOS, ability to right COG over BOS despite external stressors and distractions, and increase overall BUE strengthening. Activity utilized to enhance patient's ability to participate in shower activity without access to essential adaptive equipment, dressing at edge of bed, and BUE engagement over a sustained period of time without the premature onset of fatigue.

Patient engaged in functional mobility throughout the corridor. The indoor environment required intention and focus to increase spatial orientation and navigational skills, visual perceptual skills, depth perception, dynamic balance, stamina for gross movement, ability to incorporate ambulation aide in everyday mobility. The patient ambulated approximately 200ft with CGA and no c/o of fatigue or discomfort. Activity utilized to enhance participation in independent indoor/outdoor mobility, participation in IADLs, and traversing obstacles without risk of fall.

The patient engaged in functional ambulation training with 3 intermittent hurdles (aerobic steppers) for a total of 200ft with 2.5 minute rest breaks every 50 ft. The patient was required to ascend and descend a total of 9 hurdles with Moderate A x1 using a gait belt throughout the task. The patient demonstrated muscle imbalances throughout the pelvic region creating an atypical gait pattern requiring verbal and tactile cues to correct throughout the task.

The patient engaged in a dual-tasking obstacle course designed with alternating (3) hurdles with 6" rise 2" run and (3) aerobic steps 8" rise by 13" run to simulate various obstacles required during continuous community mobility. The patient was given 2-4 instructions varying between the difficulty of single-step and multi-step commands in order to assess and enhance working memory, topographical orientation, selective attention, sustained attention, and emotional regulation under pressure.

The patient engaged in a multi-modal diagonal hop-to ambulation pattern around cones placed 14-18"" apart while maintaining balance and postural alignment in rhythmic coordination to a metronome at 56-75bpm. This task is purposed to elicit and improve agility, movement absorption, eye-foot, eye-hand coordination, visual-spatial awareness, Gross Strengthening, improved postural alignment during functional ambulation, and dynamic standing balance resulting in greater perceived confidence in ability to be independent and increased self-sufficiency in ADLs and IADLs requiring the aforementioned performance skills. The patient stated he has experienced success with these activities at home where he has attempted them ""once or twice"". The patient demonstrated hesitancy at first, but increased in dynamic mobility and confidence by the end of the activity which was broken up into two parts, seperated by modified jogging. Each set required clearance of appx 9 cones over 20ft and consisted of appx 4-6 sets. The patient reports this is a good challenge"

The patient engaged in a multi-modal obstacle course requiring figure 8 ambulation pattern around cones placed 14-18" apart while holding 5# kettlebells, clearing hurdles of various colors and depths, maintaining balance after stepping up on an unstable surface, and retrieving various small items in order to improve fine motor coordination and strength. This task is purposed to elicit and improve agility, movement absorption, eye-foot, eye-hand coordination, visual-spatial awareness, Gross Strengthening, improved postural alignment during functional ambulation, dynamic standing balance, and fine motor skills resulting in greater perceived confidence in the ability to be independent and increased self-sufficiency in ADLs and IADLs requiring the aforementioned perfomance skills.

Patient engaged in a 3 minute period of self-initiated therapeutic rest demonstrating good self-awareness of physical limitations. Patient educated in pursed-lip, diaphragmatic breathing to promote increased participation in activity without early-onset fatigue.

Patient engaged in a 3 minute period of therapist-initiated therapeutic rest due to notable signs and symptoms of fatigue and perceived exertion of 7/10 in order to provide a period of Patient education in pursed-lip, diaphragmatic breathing to promote increased participation in activity without early-onset fatigue. Patient education regarding self-identification of physical fatigue and distress to promote safety and decrease the risk of falls.

The patient was offered education provided regarding scar management and massage. Encouraged patient to massage scar up and down, side to side and making small circles with light pressure to decrease the risk of adhesions.

The patient was educated on diaphragmatic breathing strategies to prevent shallow breathing and decreased oxygen saturation. He was taught a hand-over-hand strategy on the diaphragm to use as a visual cue for efficient breathing mechanics in order to maximize energy and promote long-term pulmonary wellness.

The patient was educated on energy conservation techniques and strategies to use while engaging in routines of activities of daily living and instrumental activities of daily living to prevent premature onset of weakness and maximize participation in meaningful activities without risk of injury/harm.

The patient was educated on proper seating and standing posture to decrease muscle imbalances and promote long-term outcomes of therapeutic interventions.

The patient was educated on the importance of including affected extremity in all ADLs, IADLS, and other occupations using bilateral training as an EBP for motor learning in order to promote neural plasticity and neural re-patterning, provide cortical organization, amplify return of functional mobility, and maximize independence.

The patient was educated on the signs and symptoms of muscle imbalances. More specifically, he was educated regarding muscle imbalance of quadratus lumborum and glueteus medius and given a home exercise program to increase the strength of surrounding muscles, elongate the shortened muscles and increase muscle tone. The patient demonstrated a good understanding of HEP as evidenced by a verbal and physical explanation of the assigned tasks.

The patient was offered clinical rationale regarding plan of care approach and current therapeutic outcomes to this date. Neurocentric rehabilitation explained to the patient including the 12 core elements of the approach and the clinical rationale surrounding current treatment goals. The patient is in agreement with the collaborative approach for intended outcomes.

The patient was offered paraffin bath therapy intervention to prepare affected aspects of hand/wrist for therapeutic exercise. Paraffin causes temperature increases of 7.5°C in the joint capsule and 4.5°C in muscle and have a local effect of relaxing the smooth muscle fibers in arterioles, which in turn results in the vasodilatation of the peripheral blood vessels. This produces hyperemia, increased transduction of tissue fluid, increased lymph flow, and the absorption of exudates which promotes the physiological components of healing partnered with crucial therapeutic exercise and activity. The patient's skin was monitored throughout without concern. The patient reported feeling "looser" after taking off the paraffin. No complaints or concerns noted.

The patient collaborates with the occupational therapist to apply and utilize TENS unit with targets placed on bilateral gluteus maximus/minus regions 300 Volts / 2.5 power in order to elicit a natural analgesic effect on the pelvic region and reduce pain during rehabilitative exercises and activities as well as provide increase muscle activation throughout weaker muscle segments. The patient responded well to intervention without c/o of discomfort.

Vibration therapy utilized as a prepatory method to increased neuromuscular communication and encourage awareness of the brain to the area of the body going to be engaged as well as increase circulation surrounding specific body part to prevent muscle injury or premature onset of fatigue. No pain or concerns noted by patient at the termination of this activity

The patient was offered moist heat for approximately 8 minutes on the upper thoracic/cervical spine and pectoralis major mm as a preparatory modality to increase vasodilation and increased blood flow to prepare the muscle for activity, decrease muscle spasm or risk thereof, increase the elasticity of connective tissue, and provide pain relief. The patient reported positive effects and did not offer complaints. Skin checked continuously to ensure the safety of the client.

The patient was offered cold therapy using clay-pack ice-pack for 8 minutes to reduce the metabolic rate of tissue thoughout the right shoulder, decrease risk of subsequent edemia, decrease pain, and increase long-term results of skilled therapeutic joint mobilizations and physical medicine rehabilitation. Monitored skin thoughout time lapse without concern. The patient reported "feeling good" after modality and denied any discomfort or concerns.

The patient engaged in aerobic activity while seated without back support using the UBE (arm bike) and BUE for 12 consecutive minutes at medium resistance in order to improve cardio-pulmonary efficiency, core/back strength, BUE strength, muscle stamina, and endurance. Exercise used to improve functional mobility in the community and prevent premature onset of fatigue while grocery shopping and volunteering.

The patient engages in a static sitting open kinematic chain BUE strengthening exercise requiring her to use a cylindrical grasp to reach for, stabilize, and move a weightless bar from point an (anteriorly placed outside BOS) to point b (within BOS and proximal to her line of gravity) against the resistance of a yellow theraband. The patient performed pronated elbow flexion/extension exercise with sustained isometric shoulder flexion contraction at 90˚ got 2x12 repetitions. It is noted that the patient was able to maintain a static sitting posture against gravity for the entirety of the activity with 3 verbal cues for re-engagement of postural muscles.

Vertical Position - The patient used a rocker board in the vertical position to elicit plantar and dorsiflexion of B feet in order to increase ankle mobility and joint support for functional ambulation/transfer improvement as well as increased agility and movement absorption. 2x10

The patient used a rocker board in the vertical position to elicit inversion and eversion of B feet in order to increase ankle mobility and joint support for functional ambulation/transfer improvement as well as increased agility and movement absorption. 2x10

The patient engaged in total body preparatory exercise using the NUSTEP for a duration of 8m to elicit AROM from BUE and BLE by way of a contralateral movement pattern invoking both sides of the neural cortex. Exercise used to increase activity tolerance, cardiopulmonary endurance, muscle stamina, and gross coordination. Education provided for efficient breathing mechanics and the importance of physical activity in therapeutic outcomes.

The patient engaged in a sit-to-stand exercise requiring CGA-Mod Ax1 to complete 15/15 repetitions using a yellow theraband around knees to provide visual and proprioceptive input for body positioning and kinesthetic performance. Pt. education given for proper body mechancis, safety awareness, and performing diaphragmatic breathing during transitions Kinesiotherapeutic technique used to habitualize pt's physiological ability to bring and maintain COG over BOS and establish strong BOS when transitioning from sit to stand for increased efficiency in functional transfers, functional ambulation, ability to engage in complex ADLs such as toileting without premature onset of fatigue, and bed mobility.

The patient engaged in a sit-to-stand exercise requiring CGA-Mod Ax1 to complete 15/15 repetitions using a yellow theraband around knees to provide visual and proprioceptive input for body positioning and kinesthetic performance. Pt. education given for proper body mechancis, safety awareness, and performing diaphragmatic breathing during transitions Kinesiotherapeutic technique used to habitualize pt's physiological ability to bring and maintain COG over BOS and establish strong BOS when transitioning from sit to stand for increased efficiency in functional transfers, functional ambulation, ability to engage in complex ADLs such as toileting without premature onset of fatigue, and bed mobility.

The patient used yellow theraband resistance to increase strength in intrinsic/extrinsic hand muscles, forearm and BUE strength (with emphasis on RUE) - Movement patterns performed included parallel extension grasp, internal/external rotation, and shoulder protraction/retraction. 2x10 repetitions activating multiple muscle groups simultaneously.

The patient used yellow theraband resistance to increase strength in intrinsic/extrinsic hand muscles, forearm and BUE strength (with emphasis on RUE) - Movement patterns performed included parallel extension grasp, internal/external rotation, and shoulder protraction/retraction. 2x10 repetitions activating multiple muscle groups simultaneously.

Patient engaged in BUE strengthening routine using 5# weighted bar completing 2x15 reps of each set for increase mm stamina during w/c transfers, bed mobility, UB dressing, and grooming without the premature onset of fatigue. The exercise circuit elicited an isotonic contraction through the following movement patterns: shoulder press, bicep curl, and forward row.

Patient engaged in BUE strengthening routine using 5# weighted bar completing 2x15 reps of each set for increase mm stamina during w/c transfers, bed mobility, UB dressing, and grooming without the premature onset of fatigue. The exercise circuit elicited an isotonic contraction through the following movement patterns: shoulder press, bicep curl, and forward row.

Patient engaged in dynamic sitting exercise holding 2# weighted bar requiring the elicitation of forward flexion to floor level with subsequent seated row when returning to midline 2x 20/20 reps with therapist initiated rest break between sets. Movements enhance the ability to center mass over BOS while seated for improved ability to don pants at floor level and increase participation in self-care. Activity enhances BUE strength, core/postural stability, and tolerance for controlled movement to increase safety awareness and prevent falls d/t generalized weakness.

The patient received neuromuscular stretching for the bilateral lower extremities. The goal is to increase the patient’s range of motion, provide an optimal elongation of the musculature, and tone management from pt’s CVA. The therapist provided stretch to the hamstrings, hip flexors, piriformis, hip abductors and quadratus lumborum. In addition, the therapist stretched gastrocnemius, soleus and calf muscles, and the peroneus longus and brevis tibialis posterior responsible for ankle eversion and inversion. A 10-sec hold followed by a 5-sec period of resistance was done with each motion therapist performed x3 repetitions.

The patient engaged in a slow stretch with minimal bodyweight for loadbearing incorporation. The patient performed exercise against the wall in a modified wall-push up and also in quadruped on floor level with wrists in extension and hands pointing toward legs. The patient states she was applying approximately equal weight through the left and right hands at this time. Exercise used to promote muscle elongation + strengthening.

The patient engaged in flexion and extension/rotation holding a 2# weighted ball to elicit a functional movement pattern with isometric contraction at the end range of extension for 3 seconds x 10 reps. Fatigue noted at the conclusion of activity - patient denied pain/discomfort.

The patient engaged in upper extremity static stretching based on therapist visual demonstrations. Stretching was performed actively by the patient. The task was completed 5 times with an 8-second hold to provide an optimal elongation of the triceps, deltoid and trunk. The performance of static stretching will allow for a greater range of motion in the extremities and increased performance in daily occupations.

The patient engaged in arm strengthening activity using a red forearm flexor with 10 reps with hands holding the object in pronation and 10 reps in supination. Education given to maintain proper body mechanics with elbows pinned to the sides of thoracic cavity. The resistance encouraged gross BUE strengthening and muscle elongation with purpose of enhancing wrist control and stability against resistance.

The patient engaged in bilateral foot/ankle strengthening exercises using yellow theraband for in toe/out toe (popliteal strengthening and stretching), dorsiflexion, and plantar flexion 2x10 each movement pattern / each foot.

The patient engaged in standing core/trunk and tricep strengthening activity while pressing chest against exercise ball to elicit balance reaction, postural stability, and an erect posture. The patient held a weightless bar and performed 3x10 tricep strengthening exercises with 1x5 5 seconds sustained isometric contractions.

The patient engaged in AAROM of RUE working proximally to distally (shoulder flexion, shoulder abduction, adduction, external rotation, internal rotation, elbow flexion, elbow extension, wrist flexion/extension, fingers flexion/extension, abduction/adduction) within 2 planes (15 repetitions each movement) in order to decrease tone, increase strength and mobility, and re-establish correct movement patterns for ongoing independence with ADLs and IADLs important to his quality of life. The patient is noted to have ongoing hemiplegia in RUE and demonstrates elicitation of AROM to approximately 40% of WNL due to continued mm. weakness.

The patient engaged in fine motor strengthening exercises of the intrinsic and extrinsic musculature of the hand as well as gross forearm musculature using the power web tool with moderate resistance. The patient performs hook, cylindrical, and spherical grasp functional movement patterns against resistance 2x10 concentric contractions with 3-second isometric contraction at the end position. Slow eccentric release encouraged when returning to the first position during each repetition. The patient was offered a rest break intermittently. No complaints of discomfort noted throughout the intervention or at the termination of activity.

The patient engaged in a wrist AROM sequence eliciting wrist flexion/extension, circumduction, rotation, pronation/supination, radial/ulnar deviation. The patient was instructed to perform each movement slowly, methodically, and with complete control. No pain or discomfort verbalized by the patient, though the patient affirmed muscle fatigue at the end of the sequence. Therapeutic rest was given after task.

The patient used the flexxfix hand system to improve various functional pinch patterns including tip punch, chuck pinch, and lateral pinch. The patient was required to use the "Soft" yellow egg for tip pinch exercise and the "medium" red egg for chuck and lateral pinch exercises. Activity performed with 10 concentric isotonic contractions to full range and the three-second isometric hold at end range. Therapist-initiated termination of each set at 5 repetitions due to threshold before at least 5/10 pain experienced vocalized by the patient.

The patient used the flexxfix hand system to improve various functional grasp patterns to strengthen patient-stated deficits of spherical and cylindrical grasp performance during functional activities like opening jars and containers. The patient was required to use the medium "green" resistive ball to perform exercises activating the three mm of the thenar eminence and surrounding supporting and stabilizing structures. Activity performed with 10 concentric isotonic contractions to full range and the three-second isometric hold at end range. The patient able to complete an activity but required cryotherapy for approximately 4 minutes immediatelyfollowing activity for pain management and relaxation.

The patient engaged in AAROM of RUE working proximally to distally (shoulder flexion, shoulder abduction, adduction, external rotation, internal rotation, elbow flexion, elbow extension, wrist flexion/extension, fingers flexion/extension, abduction/adduction) within 2 planes (15 repetitions each movement) in order to decrease tone, increase strength and mobility, and re-establish correct movement patterns for ongoing independence with ADLs and IADLs important to his quality of life. The patient is noted to have ongoing hemiplegia in RUE and demonstrates elicitation of AROM to approximately 40% of WNL due to continued mm. weakness.

Remember that these notes can be interchanged, these are JUST EXAMPLES to help you process defensive documentation

This task is purposed to address symptoms of movement initiation, coordination, and control associated with her primary diagnosis. Metronome training has been proven to increase the accuracy of the central motor impulse and therefore the impulse force of the nerve over which the command is issued. Consequently, the regulation of the skeletal muscles by the central nervous system can reinforce the coordination between agonizing-antagonist muscles. Due to the rhythmic auditory signals activating the motor neuronal spinal nuclei through the reticulospinal pathway, metronome-based interventions train the coordination of axial and proximal movements by motor commands. This increased excitability on this pathway decreases muscle reaction time to improve volitional mobility during that patient's functional performance.

The patient engaged in seated BUE AROM kinetic activity requiring rhythmic coordination with the metronome at 55BPM in various UE functional movement patterns. Today's session targeted shoulder flexion-extension with maximum difficulty. Due to cognitive demands, the patient had difficulty understanding how to execute this task and therefore had maximum difficulty coordinating movements to beat. The patient continuously offered feedback that she was not able to move either hand in conjunction to beat as her movements would either be too big or too small implying modulation deficits. The patient requires further sessions to maximize performance in this EBP. This task is purposed to address symptoms of movement initiation, coordination, and control associated with her primary diagnosis. Metronome training has been proven to increase the accuracy of the central motor impulse and therefore the impulse force of the nerve over which the command is issued. Consequently, the regulation of the skeletal muscles by the central nervous system can reinforce the coordination between agonizing-antagonist muscles. Due to the rhythmic auditory signals activating the motor neuronal spinal nuclei through the reticulospinal pathway, metronome-based interventions train the coordination of axial and proximal movements by motor commands. This increased excitability on this pathway decreases muscle reaction time to improve volitional mobility during the patient's functional performance.

The patient engaged in a dynamic standing activity requiring unilateral LE balance over 1 second while performing a toe-tapping activity to reach the target for the purpose of increasing BLE modulation and eye-foot coordination during functional mobility activities. The patient was not able to perform greater than 1 second unilateral LE stance demonstrating atypical weight-shift but was noted to complete the task successfully using rhythmic coordination of metronome at 60 BPM. The patient required moderate education and verbal cueing for auditory processing and motor praxis.

The patient engaged in full body static stretching session in order to increase ROM, decrease noted hypertonicity, and increase quality participation in daily activities. Research has posited that static stretching decreases muscle spindle activity and motor neuron excitability, increases muscle compliance and changes in fascicle angles and orientation, and increased stretch tolerance. The patient was stretched through the following motions for 8-10 reps with a 10-second hold at the end of each repetition: shoulder flexion, extension, abduction, and internal/external rotation, forearm flexion and extension, hip extension and flexion (to target hamstring complex), gastrocnemius, and tibialis anterior and posterior.

The patient engaged in proprioceptive neuromuscular facilitation of the LUE to promote decreased spasticity and increase ROM performing 2 sets of 10 reps through D1 and D2 movement patterns. The patient was educated on observed compensatory movements through SCM and scalene musculature. The patient demonstrated an understanding of education as evidenced by increased intention throughout the activity.

The patient engaged in passive neuromuscular inhibitory passive range of motion intervention while seated with back support in preparation for today's therapeutic interventions. Sustained passive range of motion with a terminal stretch of the spastic muscles working from proximal joints of the extremity to distal joints in a rhythmic motion is supported to diminish spasticity to a level where voluntary movement may have increased potential to be facilitated. The patient was encouraged to relax and was educated regarding the influence emotions have on muscle tone. The patient responded well to inhibitory stretching right upper extremity with minimal residual spasticity remaining in the 2nd-4th digit.

The patient engaged in NMRE with emphasis on postural control and ability to right to midline through static standing, visualization, and neurodevelopmental technique/feedback at the pelvis and shoulder girdle. The patient was educated in muscle isolation and contraction to create muscle balance between eccentric and concentric contraction resulting in improved posture. Establishing COG over BOS appropriate for gender and ability will enhance functional transfers and ambulation. The patient was encouraged to thrust the pelvis forward creating a posterior pelvic tilt to decrease lordotic posturing and help elicit back extension. The patient was instructed in exercises that can be conducted throughout the week via HEP to enhance posterior pelvic tilt and back extension. 10 x 30-second reps of holding proper posture with therapist assist.

The patient collaborated with the occupational therapist through neuromuscular massage for 16 minutes by eliciting a slow progressive static stretch of the right hip flexor and quadratus lumborum combined with active range of motion through the muscle full available range. During the patient’s active movement, the therapist guided the patient with moderate proprioceptive input using an MFR aide in order to realign the fascial plane, rest the soft tissue proprioceptive sensory mechanism, and promote a normal functional range of the right lower extremity. Neuromuscular massage conducted through skilled services to decrease pain and repeated stress placed on the soft tissue of the body due to inactivity and forming fibrous adhesions. These adhesions have ultimately inhibiting appropriate body mechanics causing a cyclical occurrence of pain, joint discomfort, decrease motor-firing, decreased soft-tissue extensibility, and decreased participation in ADLs, IADLs, and meaningful occupations.

The patient began the treatment with a gross AROM movement routine designed to promote neuronal excitation, brain plasticity, interhemispheric communication, balance, agility, visualization, and stability. 15 reps for each movement set including Starfish (simultaneous BUE cross midline, internal rotation, adduction > outside BOS, external rotation, abduction, and shoulder flexion), alternating PNF D1 patterns, Alternating toe taps crossing midline using a visual target to ensure maximum range and visual perceptual skills, and Cross crawl marching while creating gross muscle tone/tension through visualizations.

The patient collaborated with the therapist to utilize guided volitional muscle contractions with deep neuromuscular massage for the release of tight muscles and entrapments with the purpose of decreasing chronic pain and restoring balance among large muscle groups. Target areas include the gluteal region, lower back, hip flexors and extensors.

The patient engaged in pelvic and lower body mm stretching with an amplified focus on the elongation, release, and correction of muscle imbalances affecting the piriformis, gluteus minimum, and triple gemellus mm in order to decrease and prevent chronic pain through hips and increase homeostatic support in order to decrease pain and increase quality participation in ADLs/IADLs.

Patient participated in agility-centered activity using a high contrast agility ladder to invoke the vestibular, neuromuscular, muscular, and visual perceptual body systems in order to increase balance, gross coordination, visual perception, agility, invoke involuntary postural correction, attention to task, motor planning, movement intention, and neuromuscular communication. The patient demonstrated difficulty in performing a forward linear pattern which required him to alternate between a narrow BOS and wide BOS x6 step sequence. CGA with x4 errors requiring verbal and visual cues.

The patient engaged in gait and locomotion training to enhance neuromuscular control of hip, knee, and ankle joint stability as well as back extension and postural response in order to improve functional mobility in-home and community using ambulation aid. The patient was able to walk 100ft with the therapist walking on the left side offering handheld assist and min Ax1 at the gait belt in order to decrease left-sided neglect and weight-bearing avoidance.

The patient engaged in speed ambulation over 40 ft to improve the ability to sustain altering speed and adapt to variable stimuli with current performance skills while maximizing secondary benefits of memory, visuospatial ability, executive function, and processing speed. 5 Trials.

The patient engaged in functional ambulation training to improve his transfers from w/c to the chair and sit-to-stand postural changes. The patient performed w/c to chair transfer with minimum assistance due to safety concerns. The patient is able to ambulate approximately 5 ft with the therapist-assist using neuromuscular facilitation at his 2 proximal points of control (hip and pelvis). The patient demonstrated maximum difficulty and ataxic gait pattern throughout the activity.

The patient engaged in gait and locomotion training to enhance neuromuscular control of hip, knee, and ankle joint stability as well as back extension and postural response in order to improve functional mobility in-home and community using ambulation aid. The patient was able to walk 100ft with the therapist walking on the left side offering handheld assist and min Ax1 at the gait belt in order to decrease left-sided neglect and weight-bearing avoidance.

The patient engaged in tandem gait pattern to reduce trunk-tilt, the center of mass displacement, medial-lateral feet distance, and frequency of stepping error as well as increase lateral support strengthening, trunk/core support, movement intention, and eye-foot coordination in order to improve community mobility. Walking in tandem has been proven to promote increased strength, gait stability, neural excitation for greater plasticity, and increased carryover into other functional movements. The patient performed the 20 ft tandem 10x in total requiring him to pause at various targets and perform 6 alternating contralateral connections of elbow and knee. This task invoked neural plasticity, interhemispheric activation, amplified recruitment of gross motor units, modulation, and BUE/BLE coordination. The task proved to be challenging, and the patient requested a rest break every 40ft.

The patient engaged in tandem gait pattern to reduce trunk-tilt, the center of mass displacement, medial-lateral feet distance, and frequency of stepping error as well as increase lateral support strengthening, trunk/core support, movement intention, and eye-foot coordination in order to improve community mobility. Walking in tandem has been proven to promote increased strength, gait stability, neural excitation for greater plasticity, and increased carryover into other functional movements. The patient walked approximately 30-40 ft CGA without the use of an ambulation device with moderate difficulty and verbal cues throughout the entire task to slow down and focus on stable movements. The patient was not able to exemplify a complete tandem pattern and was off by approximately 50%.

The patient engaged in a neuromuscular enhancement activity requiring coordination, the ability to judge the height and depth of a 7" high 1" wide obstacle (6 total), stride length to clear the obstacle, and the demonstrate the ability to maintain attention to a task despite environmental distractions demonstrating safety awareness. The patient was required to walk in a linear pattern initially to familiarize self to task and gauge a baseline for coming treatments. The patient able to clear 5/6 in the first trial 6/6 in the second trial, and 4/6 in the third trial demonstrating premature fatigability, muscle weakness, possible visual deficits, and deficits in neuromuscular communication requiring further treatment. The patient was able to perform the activity with CGA and a gait belt.

The patient engaged in gait and locomotion training to enhance neuromuscular control of hip, knee, and ankle joint stability as well as back extension and postural response while eliciting normalized motor recruitment of the muscles activating dorsiflexion in order to improve functional mobility in-home and community. The patient was able to walk 100ft using a cane for postural enhancement while using a corrective aid on the left foot to normalize the heel strike toe-off mobility pattern. Two sets performed to promote neuromuscular re-education.

The patient engaged in slow contralateral marching to promote neural re-patterning, neural organization, enhancement of cognition, and interhemispheric communication. The patient slowly raised the contralateral upper and lower extremity in a holding pattern to maximize intentional motor activation, increase hip, knee, and ankle stability, while also promoting UE strengthening and flexibility. The patient performed 50 marches on each side with minimal difficulty and contact guard assistance.

The patient engaged in a seated multi-modal activity requiring holding a weightless bar with BUE at 90 degrees of shoulder flexion while isolating hip abduction/adduction keeping a ball from falling while moving between trunk forward flexion and posterior extension and return to the midline. The patient performed 2x10 repetitions without complaints of pain or discomfort. Notable muscle fatigue noted post-activity requiring rest prior to the next task

The patient engaged in a heavy-work obstacle course requiring engagement for 10 consecutive minutes fulfilling 10 repetitions with CGA and tactile cues AAT for direction and focus to the task. Obstacle course used to address several deficits including Functional ambulation addressed with 2 steps placed throughout course with the variable rise and semi-circle turning to promote agility, balance, and ambulation efficiency. Lower body strengthening and balance training invoked by way of patient participation in stepping up to and balancing on an aerobic stepper x2 while carrying variably weighted balls from 2lbs to 5lbs (6 balls total) requiring the patient to elicit trunk/core muscles throughout the course.

The patient engaged in NMRE activity sequence requiring standing on an uneven foam pad and performing a series of stepping sequences to engage automatic postural support muscles, neuromuscular system, and joint stability mechanism while maximizing neuronal plasticity. The patient performed alternating BLE side steps to target with anterior kicks for completion as well as alternating front kicks to a target approximately 6 inches above balance pad level. 2x15 reps in each direction, CGA for stability, the patient used BUEs for support.

The patient engaged in an activity requiring numerous elements of short-term memory, attention to detail, alternating attention, delayed recall, and extrapolation. The patient was given (1 to 2) 2-sentence statements with specific details and then required to correctly answer 4/4 questions about each statement. The patient was able to successfully answer 100% of the questions x 8 statements.

The patient engaged in a face-recognition activity to remediate and restore normal face-processing mechanisms by way of visial-cognitive training. The patient was required to remember 6/6 faces with first and last names and make associations with each image. The patient was given 2.5 minutes to review faces and the names were removed. The patient was able to recall 4/6 first names before requiring a second attempt. During the second attempt, the patient was given 1.5 minutes to review before names disappeared. At this point, the patient was able to repeat 5 of 6 first and last names accurately. In the third trial, the patient was given 30 seconds to review. During the third attempt, the patient was able to successfully name the first and last names of each person

The patient engaged in a multi-modal auditory memory and functional cognition task requiring alternating attention and the ability to process (2) alternating short 4-paragraph stories read at 1 paragraph intervals at a slow pace immediately followed by unrelated social conversation and subsequent completion of 18/18 questions regarding both stories, the patient was then required to recall details of the initial story using echoic/auditory memory in the recall process. The patient was able to correctly answer 13/16 questions correctly demonstrated good improvement and excellent therapeutic potential to reaching goals.

The patient engaged in 5/5 trials of a medium difficulty STROOP test. Activity purposes to increase attention to a task requiring high cognitive demand in pre-frontal cortex functions. Stroop is used to assess and improve the cascade of control between neurocognitive brain functions required to exhibit cognitive control when manipulating task-relevant and task-irrelevant information. The patient must use cognitive control to overcome the tendency to read the word and base a decision on that information to prioritize the processing of ink color so as to guide responding. The patient had a good understanding of the directions of this task and was able to complete this task [objecgtive measure to follow]. The patient reports feeling a slight headache. Therapeutic rest offered until the patient felt comfortable to continue with the activity. 4 Lines, 5 words per line. T1 - 1 minute 8 (2 errors) T2 - 34 seconds, no errors. Increase headache as the patient said she looked at words through her peripheral to avoid confusion of what was being read. The patient was educated regarding the importance of reducing visual strain during concentration and embracing the challenge of the activity while utilizing wellness strategies like closing her eyes, resting before continuing to the next line, taking increased time. T3 - 44s no errors

The patient was introduced to the STROOP test through participation in a simple 3 line 8-word Stroop activity. Activity purposes to increase attention to a task requiring high cognitive demand in pre-frontal cortex functions. Stroop is used to assess and improve the cascade of control between neurocognitive brain functions required to exhibit cognitive control when manipulating task-relevant and task-irrelevant information. The patient had a good understanding of the directions of this task and was able to successfully complete it with 100% accuracy. The patient was educated regarding the continuum of grading that will take place using the STROOP phenomenon. Slight 'head heaviness noted at the end of this simple activity that took 44 seconds to complete.

The patient engaged in counting backward exercises today as the executive function and neurological-based multi-modal activity used in conjunction with auditory memory enhancement training. Because counting forward and backward rely on canonical (Broca and Wernicke) language areas, incorporating counting activities into memory-enhancement training will allow for the activation and excitation of critical language functions affected by traumatic brain injury. Furthermore, in both forward and backward counting, studies have suggested pre-frontal cortex activation which plays a critical role in the storage and manipulation of information in working memory. The patient demonstrates moderate difficulty counting backward between auditory memory activities as evidenced by the following outcomes: T1 count 100 to 50 by 3 = 9 errors T2 count 0-50 by 2 = 7 errors and slow T3 count 50-0 by 3 = 9 errors and slow

The patient engaged in a digit span and registration activity for the remediation of short-term verbal memory. The patient was assigned a digit span of 5 numerical values and measured for forward and reverse-order (backward) recall of digit sequences. The optimal sequences are as follows: 9 digits forward, 8 backward. 7 sets performed total with increasing information processing difficulty noted. T1 - No errors T2 - No errors T3 - 1 error T4 - 4 errors, 5th success T5- No errors T6- 3 erros, 4th success T7 5 errors Task terminated due to cognitive fatigue

The patient engaged in a Figure-ground perception-based activity for the enhancement of visual memory. Figure-ground perception is an important aspect of visual processing and is necessary for attention, encoding, and consolidation of memory. The patient was able to review a photo with 30+ items for 30 seconds. After viewing, the patient engaged in an executive function activity requiring calculations, digit span rehearsal forward/backward, and STROOP. Despite alternating attention required for the completion of secondary activities, the patient was able to successfully list 15 items with the corresponding numeric presentation without difficulty. This demonstrates good visual short-term memory.

The patient engaged in a multi-modal auditory memory and functional cognition task requiring the processing of a short 4 paragraph story read at a slow pace immediately followed by the requirement of functional math word problems and basic calculation questions. Subsequent to completion, the patient was then required to recall details of the initial story using echoic/auditory memory in the recall process. The patient was able to correctly answer simple math requirements of the task but demonstrated moderate difficulty utilizing auditory memory to recall details of the story verbalized after approximately 6-7 minutes. Each text required a re-reading which read quicker than the time before. Out of 8 questions, the patient was able to recall 4 in the first trial and 6 in the second trial. The patient noted that auditory memory is very difficult for her.

The patient engaged in an auditory sequential memory task requiring the memorization and recall of a strand of related words. The task was purposed to improve short-term memory, invoke attention, and engage the encoding process required for echoic memory. The patient was required to remember 2 item sequences to 6 item sequences of related words that were also meaningful to the client. Successfully complete 2-3 word spans without error after a 10-second pause, but required 2+ trials after being asked to immediately recall 4 or more word sequences. The patient required rest after activity secondary to feeling "a little more tired."

The patient engages in approximately 12 minutes of neuromuscular re-education through proprioceptive manipulation, muscle elongation, and application of dermal material to decrease support scapular mobility, decrease edema, and increase homeostatic support in order to decrease pain and increase quality participation in ADLs/IADLs.

The patient engages in neuromuscular re-education training and collaboration with a clinician to introduce an intervention that will promote proprioceptive manipulation, muscle elongation, and application of dermal material to decrease nerve compression and increase homeostatic support in order to decrease pain, decrease spasticity, and increase quality participation in ADLs/IADLs. The patient and caregiver demonstrated understanding and comprehension of education as evidenced by the signed waiver at the time of visit. Test strip applied without signs of discomfort.

Patient engages in approximately 12 minutes of neuromuscular re-education through proprioceptive manipulation, muscle elongation, and application of dermal material to decrease nerve compression and increase homeostatic support in order to decrease pain and increase quality participation in ADLs/IADLs.

The Patient engages in approximately 12 minutes of neuromuscular re-education through proprioceptive manipulation, muscle elongation, and application of dermal material to provide ongoing proprioceptive input to the patient between sessions thus promoting the brain's awareness of the RUE and decreasing right-sided neglect.

The patient engaged in a dual-tasking activity with emphasis on visual memory and recall. The task required the patient to receive a 3-part image at point A, ambulate 20 ft while clearing obstacles of various sizes and heights, and recall and draw the image received at Pt A. This activity is purposed to improve the relationship between perceptual processing and encoding, storage, and retrieval of the resulting neural representations after approximately 10 seconds of time-lapse. The patient demonstrated no evidence of LOB or instability. She required between 2-3 repetitions per image with 2-3 verbal cues. 3 step directions are moderately difficult for the patient.

The patient engaged in cognitive-motor dual-tasking techniques leveraging motor-based practices on the rate of interhemispheric communication to elicit neuronal excitation overflow into executive functioning and increased functional independence. The patient was verbally assigned a series of 4 numbers prior to speed walking 20 ft and required to rehearse the numbers assigned. The patient successfully completed 3/4 trials of 4-digit sequence while whispering to herself for self-initiated verbal cueing demonstrating the need for refinement of dual-tasking skills

The patient engaged in cognitive-motor dual-tasking techniques leveraging motor-based practices to improve the rate of interhemispheric communication to elicit neuronal excitation overflow into executive functioning and increased functional independence. The patient was assigned a 6-step movement pattern with BUE to accomplish prior to repeating a 5 digit numeric sequence that was verbally assigned. The patient was required to pause for 12 seconds prior to repeating the numeric sequence to the practitioner. The patient completed 6 x 5 digit sequences requiring 3 trials per digit sequence to remember the entire unit of numbers.

The patient engaged in a dual tasking activity with emphasis on visual spatial skills and abstract thought. The patient was required to stand in the middle of a large circle representing a clock face with a colored target placed at 12 o'clcok, 3 o'clock, 6, and 9. The patient was required to remember between 1-5 numbers and tab the number of the clock with alternating BLE. This task purposed to exercise and enhance visual memory of a clock face, the ability to remain attentive for a prolonged period of time, concentration, spatial reasoning, abstract thought, and recall.

The patient engaged in a dual-tasking obstacle course designed with alternating (3) hurdles with 6" rise 2" run and (3) aeorbic steps 8" rise by 13" run to simulate various obstacles required during continuous community mobility. The patient was given 2-4 instructions of varying difficulty requiring the recall of both single step and multi-step commands in order to assess and enhance working memory, topographical orientation, selective attention, sustained attention, and emotional regulation under pressure.

The patient engaged in a catch/release task with medium-sized lightweight ball in variable transfer styles including bouncing and throwing at multiple heights while simultaneously alternating counts every other digit until 100. This task was used to increase postural support, reaction time, neuromuscular communication, simultaneous motor unit recruitment in BUE, and establishment of stron BOS, ability to right COG over BOS, and the ability to perform dual task activities requiring the performance of executive functions and mobility based tasks. The patient required multiple verbal cues to ensure directions were correct and increased in confidence throughout task. The patient displayed no difficulties in manipulating numbers nor did she experience LOB.

The patient engaged in cognitive-motor dual-tasking techniques leveraging motor-based practices to improve the rate of interhemispheric communication to elicit neuronal excitation overflow into executive functioning and increased functional independence. The patient was assigned a 5-step movement pattern with BUE to accomplish prior to listening and remembering 5 unassociated words that were verbally assigned. The patient was required to pause for 12 seconds prior to repeating the unassociated words to the practitioner. The patient required 3 trials to recall 5/5 words. First trial - 2 words Second trail - 4 Third trial 5 words

The patient engaged in cognitive-motor and visual memory dual-tasking techniques leveraging motor-based practices to improve the rate of interhemispheric communication to elicit neuronal excitation overflow into executive functioning and increased functional independence. The patient was required to review a detailed image for one minute, perform a previously assigned motor component (BUE pattern of 6 steps), and recall details about the image reviewed. After providing a general overview based on recall, the patient was asked to answer 5 context-based questions about the image in the first trial. The second trial allowed the patient to review the image for a second time for 30 seconds while subsequently answering the questions assigned. Movement Sequence: Successful during both trials Trial 1: 2 of 5 questions successfully answered Trial 2: 5 of 5 questions successfully answered