Student

Name: Jessica Smith Case: #5 – Charlie – PD Date: 3/24/2018

1. Diagnosis, Referral, Setting, Reimbursement, LOS

Charlie is a 72-year-old male admitted to a Transitional Rehabilitation Facility after falling and
breaking his wrist secondary to worsening symptoms of Parkinson’s Disease (PD). Charlie also has
a secondary diagnosis of bilateral cataracts. Charlie has been living independently for the last 3
years, since the passing of his late wife; his daughter Lola has been visiting in the hospital, but it is
unknown if she will be involved in caregiving upon d/c.
- Charlie’s length of stay (LOS) in Transitional Rehab Facility is for 10 days - reimbursed through
Medicare before an anticipated d/c to his home, where he lives alone.
- Charlie was referred by his physician for a short stay in transitional rehab to “fine tune” his
abilities to safely live and care for himself (ADL/IADL skills) before discharging home.
- Charlie should be receiving Occupational Therapy services every day for 10 days while in
transitional rehab; (likely for 1 hour/day, although not yet specified).
- Upon admission onto the unit, a PRN therapist performed a COPM and an ADL functional
assessment, outlining potential interest and problem areas for Charlie.

2. Pragmatic Factors to Consider

- Client’s schedule, daughter’s schedule (and willingness to be involved in care/transitioning back
to Charlie living independently in the community).
- It has been a few (unspecified) years since Charlie’s PD diagnosis. His current level of
functioning suggests that his condition has likely progressed into Stage II or Stage III
- Charlie is very motivated to return home; Lola (his daughter) seems to believe he is incapable of
doing all of the things Charlie claims to do on a daily basis – she also has stated that her father
should go to a “nursing home” – her perception may be an important factor to consider.
- What are the other team members (PT or SLT) working on in therapy, if seeing Charlie at all – it
would be important to either not overlap with their therapy goals, but it is also important to
carryover strategies taught by other disciplines, such as possible gait, transfer or balance
suggestions.
- If Charlie is currently on medication to help manage PD symptomology, it would be important to
know about the “on” and “off” cycles – especially when planning out when to perform therapy,
as well as when considering how to help Charlie organize his daily tasks/activities based on how
these cycles may help or impede his functional abilities.
- Medicare will only pay for 10 days in transitional rehabilitation – would it be possible to get
funding for some home health assistance if deemed appropriate/necessary for Charlie’s safe
return to home?
- When/if Charlie returns home, what types of modifications would be appropriate/possible? (also,
what is his home like? – How old, anything in need of repair, stairs, shower or tub/shower
combo, accessibility, etc.
- What goals can be addressed/accomplished during Charlie’s LOS?
- Any post-surgery precautions (for broken wrist).

3. Context: Occupational Profile & Current Occupations

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Cultural:

Physical: - Right hand dominance

- I – grooming
- Min A – bathing w/ shower chair (xfer and LB washing)
- Min A – UB dressing
- Mod A – LB dressing (in standing)
- Mod A – to cover cast prior to showering LE
- Mod A – to don socks – ‘struggling’
- Difficulty w/ buttons, but eventually got them done
- Charlie stated – he mostly wears slippers during the day so he doesn’t have to deal
with socks/shoes

- All ADLs took considerably longer d/t R-sided tremors and bradykinesia

- Able to feed self – but frequently spilled food (d/t tremors), and drooled
occasionally
Social: Widower for 3 years – living alone and managing fine since his wife passed away.

Personal:

Temporal: What is he really doing with his time?

Virtual:

Prior Occupations:

Current Occupations:

4: Top Three Client/Family Goals and Priorities

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1.

2.

3.

5. Diagnosis and 6. Scientific Reasoning & Evidence

Expected Course List the barriers to performance typical of this diagnosis:
Parkinson’s Disease (PD) Barriers to performance for PD:
is one of the most - Gait abnormalities
common adult-onset, - Freezing (when initiating or changing directions while ambulating,
degenerative neurologic and while writing, brushing teeth, speaking) (p. 941)
disorders. - Postural Abnormalities (flexed, stooped, with head positioned
3 classic symptoms of forward; stand with flexion at the knees and hips)
PD include: tremor, - Balance reactions (righting and equilibrium) are compromised
rigidity, and - May experience frequent falls
bradykinesia. - Dysfunction in both voluntary and involuntary movements.
- Classic Triad of symptoms include: tremor, rigidity, and a voluntary
Prevalence increases with movement disorder.
age. - Voluntary movement disturbances including akinesia (difficulty
Stages of progression of initiating movements), and bradykinesia (slowness in maintaining
PD symptoms: movement) compromises functional tasks such as driving, dressing,
1 – unilateral tremor, and eating.
micrgraphia, poor - On/off cycles of medication
endurance for previous
occupations, fatigue All of this information from Ch. 35 – Pedretti
2 – bilateral motor
disturbances, mild This link helps to distinguish between Parkinsonian dementia and Lewy
rigidity reported, Body dementia.
difficulties with https://parkinsonsdisease.net/clinical/lewy-body-dementia-differences/
simultaneous tasks,
difficulties with
executive function This is a link to a document that provides a lot of information about OT
3 – balance problems and Parkinson’s Disease
with delayed reactions, http://www.parkinsonnet.info/media/14820461/ot_guidelines_final-
difficulties in skilled npf__3_.pdf
sequential tasks
4 – fine motor control This link is put out by the National Parkinson Foundation – it is a
severely compromised, document with a lot of helpful suggestions for persons with PD.
oral motor deficits http://parkinson.org/sites/default/files/Practical_Pointers.pdf
5 – client severely
compromised

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motorically, dependent
with ADLs.

7. Practice Models Guiding Assessment and Rationale

Treatment
1. PEO PEO is a relevant model to use with Charlie d/t
how his dx of PD will/has greatly impacted the
congruence between the Person (Charlie), the
Environment (his d/c to home post-transitional
rehab stay), and the Occupations (such as his
occupational performance and participation in
ADL and IADL tasks – showering, dressing,
bill-pay, and independent living skills). PEO
can help to guide both assessment and
intervention by being aware that sometimes it is
easier (and more appropriate – especially with a
neurodegenerative condition) to make changes
to the E, or the O, rather than to the P. For
example, PEO can help OT to understanding that
by adapting the environment through an
environmental modification (such as adding use
of a shower chair, or learning to dress LB while
in a seated position), will likely be more
appropriate than attempting to change the person
(especially in regards to PD, as the symptoms
will progressively get worse, not better –
creating more safety concerns as time
progresses).

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2. Rehabilitation The use of the rehabilitation model is
appropriate for Charlie to address his PD
symptoms (tremor, bradykinesia, and decreased
control of voluntary motor movements, as well
as possible future onset of akinesia,
speech/swallow deficits, dementia/cognitive
deficits, gait problems, and balance deficits).

It is important for him to begin to utilize

3. Motor Control/ Motor Learning
adaptive techniques/compensatory strategies and
adaptations to the environment or occupation in
order to improve independence and functional
abilities, while he is in transitional rehab.
Although Charlie may not need a large amount
of AE at this time, it would be important to
educate and familiarize Charlie (and his family/
caregivers) to what types of equipment are
available – therefore, as his symptoms progress
over time, he can be aware of what
assistance/changes may be made to his
environment or to the task as his needs increase
with the progression of the disease.
The motor control component would help to
emphasize practice of learning motor
movements and control of movement during
occupational tasks (such as how to use body/
current motor abilities to enhance quality and
effectiveness of movement in a functional task.
It is important for Charlie to maximize voluntary
motor control of movements (initiating,
sustained movements, and discontinuing
movements) to participate in and successfully
perform occupations in differing contexts and
environments. Another aspect of a
contemporary motor control approach, is that it
stresses the importance of learning the entire
task, rather than just discrete parts of a task –
this is especially important when considering
that Charlie is expected to d/c to home in 10
days, where he will live independently.

8. Specific Areas of Occupation

What do you know? What do you need to know?

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ADLs ADLs
Bathing/Showering Bathing/Showering
Toileting Toileting
Dressing Dressing
Swallowing/eating Swallowing/eating
Feeding Feeding
Functional Mobility Functional Mobility
Personal Care Device Personal Care Device
Personal Hygiene and Grooming Personal Hygiene and Grooming
Sexual Activity Sexual Activity

IADLs IADLs
Care of Others Care of Others
Care of Pets Care of Pets
Child rearing Child rearing
Communication Management Communication Management
Driving/Community Mobility Driving/Community Mobility
Financial Management Financial Management
Health Management and Maintenance Health Management and Maintenance
Home Establishment/Management Home Establishment/Management
Meal Prep/Clean-up Meal Prep/Clean-up
Religious/Spiritual Activities & Expression Religious/Spiritual Activities & Expression
Safety and Emergency Maintenance Safety and Emergency Maintenance
Shopping Shopping

REST & SLEEP REST & SLEEP

EDUCATION EDUCATION

WORK WORK

LEISURE LEISURE

SOCIAL PARTICIPATION SOCIAL PARTICIPATION

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 9. Performance Skills
What do you know? What do you need to know?
MOTOR SKILLS MOTOR SKILLS

PROCESS SKILLS PROCESS SKILLS

SOCIAL INTERACTION SKILLS SOCIAL INTERACTION SKILLS

10. Performance Patterns-Habits, Routines, Rituals, Roles

What do you know? What do you need to know?

11. Activity Demands for the Client Goals and Priorities (CHOOSE 1)
What do you know? What do you need to know?

Relevance & Importance to Client – Relevance & Importance to Client –

Objects Used & Properties – Objects Used & Properties –

Space Demands – Space Demands –

Social Demands – Social Demands –

Sequencing and Timing – Sequencing and Timing –

Required Actions & Performance Skills – Required Actions & Performance Skills –

Required Body Functions – Required Body Functions –

Required Body Structures – Required Body Structures –

12. Client Factors- Values, Beliefs, Spirituality

What do you know? What do you need to know?

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 13. Client Factors- Body Functions & Structures
What do you know? What do you need to know?
BODY FUNCTIONS BODY FUNCTIONS
Specific Mental Functions Specific Mental Functions
Global Mental Functions Global Mental Functions
Sensory Functions Sensory Functions
Neuromusculoskeletal & Movement-Related Neuromusculoskeletal & Movement-Related
Muscle Functions Muscle Functions
Movement Functions Movement Functions
OTHER OTHER

BODY STRUCTURES BODY STRUCTURES

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14. Evaluation: What Assessment tools and other means of assessment will you use?
Top Down Assessment: Prioritize one Occupation to observe the client perform

Observed Occupation Rationale/How will you use this information

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I would like to observe Charlie eating a simple
meal (any of his hospital meals should do – it is
important to make sure the meal is within his
nutritional plan in the hospital – so no outside
foods should be used) that requires some utensil
use and possibly requires his hand to open and
close rapidly (picking up grapes one at a time...
etc.). If appropriate, I would potentially also
place food items/utensils around in a simulated
kitchen, requiring Charlie to retrieve items so
that I could also observe his ambulation,
dynamic standing and some executive
functioning skills.
Page 10 of 22
I would like to observe Charlie eating a simple
meal (one of his hospital meals would do fine, as
long as it requires either a spoon or a fork to
bring some food from table to mouth, and
ideally, it would require Charlie to rapidly open
and close his hand/s) within the nutritional plan
appropriate for him (regular, solids, soft
mechanical, aspiration precautions etc.) – if
possible/appropriate for Charlie’s current
abilities – I may also place part of the meal items
in various places around a simulated kitchen to
also require Charlie to ambulate around the
space, problem solve where to find items, and
see if/how he can retrieve them all and do it
safely (i.e. put his juice or milk carton in the
fridge, but his cereal box in the cupboard, etc.).
By observing Charlie eating, I would be able to
assess a broad array of physical and cognitive
skills, such as is she has any autonomic
dysfunction/dysphagia/dysarthria/decreased
speech volume/monotone speech (although these
symptoms are mostly associated with later stages
of PD, Charlie has displayed some drooling,
which may be a precursor or a suggestion that
these other oral motor problems may be possible
or present). Watching Charlie eat a simple meal
may also give an opportunity to observe
characteristics of the various stages of PD (i.e.
stage 1 = unilateral involvement of tremor &
slight rigidity when asked to open and close
hand; stage 2= requires several rest breaks, still
able to ambulate independently, etc.; stage 3 =
balance is impaired, delayed righting and
equilibrium reactions – difficulty w/dynamic
standing/walking; stage 4 = motor control
severely compromises dressing, feeding and
hygiene (i.e. wiping mouth).). This would also,
potentially, give me an opportunity to observe
Charlie during either and on or off cycle based
on medication – seeing how this may assist or
inhibit performance.
While Charlie eats, I can observe to see if any of
the above specifics occur, but I can also observe
the impact of his tremor (is it truly unilateral as
the case study suggests, or is it bilateral as the
Revised 1/9/17
 daughter suggested; does it decrease during
purposeful movement and increase during
periods of rest? Is he able to successfully use
eating utensils/ drink from a cup/straw without
substantially spilling? Etc.). Watching her may
also give me insight into some sensation abilities
(i.e. if he gets food on his face or begins to drool,
is he aware of it, and how does he respond?).
How long does it take him to eat, what areas are
the most severely impacted by his bradykinesia,
tremors, etc. It may also provide me with some
insight into his visual limitations. This would
also give me an opportunity to strike up a
conversation with Charlie to gain more
background information and begin to build a
therapeutic relationship with him, getting him to
“buy in” to the therapy/ recovery process.

eating utensils/ drink from a cup/straw without

substantially spilling? Etc.). Watching her may
also give me insight into some sensation abilities
(i.e. if he gets food on his face or begins to drool,
is he aware of it, and how does he respond?).
How long does it take him to eat, what areas are
the most severely impacted by his bradykinesia,
tremors, etc. It may also provide me with some
insight into his visual limitations. This would
also give me an opportunity to strike up a
conversation with Charlie to gain more
background information and begin to build a
therapeutic relationship with him, getting him to
“buy in” to the therapy/ recovery process.

Method/Tool Rationale/What is being Assessed

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1. Balance (Berg Balance Scale, B UE MMT, B
AROM & PROM of UEs, and B grip strength
Page 12 of 22
PD is often associated with balance and gait-
related deficits, degeneration of the substantia
nigra, resulting in weakness and decreased
ability to control motor movements, often
resulting in decreased ROM.
I would perform the Berg Balance Scale to assess
both Charlie’s dynamic sitting and dynamic
standing balance – this will help to develop a
baseline and determine functional possibilities
and any safety concerns to remain aware of
throughout treatment.
I would perform B UE MMT to also determine a
baseline and determine if one side of the body is
more affected by decreased strength than the
other side, or if it is fairly similar bilaterally.
This may also help to identify which
movements/muscle groups may be the most
challenging or the easiest for Charlie to use
functionally.
I would perform B AROM and PROM of the
UEs to create a baseline for what his current
abilities are and identify if any improvements
would be beneficial to work towards while in
rehab. – maintaining/increasing ROM is highly
recommended as a tx/exercise for individuals
with PD, and therefore would be good to assess.
I would also perform a grip test, for the same
reasons listed above, to compare bilaterally, and
to determine a baseline. This may help to
determine if utensils should be built-up, or if
heavy items meant to help stabilize a tremor
would be possible to hold onto, etc.
Revised 1/9/17
2. dementia assessment
3. Jebsen-Taylor Hand-Function Test
Page 13 of 22
PD often develops a type of dementia as a
symptom of the disease; Charlie’s responses to
his daily activity schedule and how those
responses vary from his daughter’s perception of
his ability and activity levels, as well as the
statement about Charlie forgetting to send in his
bills, cause me to want to explore if there are any
cognitive, memory or dementia related
symptoms that I should be aware of while
planning future treatments. Depending on how
my initial interactions are with Charlie, I would
decide whether to perform a memory test
applicable for PD (such as the Conceptual
Memory Test (CMT)), or so a quick general
cognitive screen (such as the Mini Mental State
Exam (MMSE)), or if it seems appropriate, I
would prefer to do a more in-depth assessment
for cognition such as Executive Functional
Performance Test (EFPT).
PD is often associated with deficits of executive
function – I would want to perform the EFPT
with Charlie to assess if any executive function
deficits are concerning or severely impacting his
ability to perform ADLs and IADLs, or live
independently in the community safely –
additionally, there is a bill paying portion, which
is something that he stated being concerned
about/interested in.
Charlie has been expressing that his hands are
not working as they use to, and that his
handwriting is becoming worse and illegible to
the point of him being concerned his checks
wouldn’t be accepted. The Jebsen-Taylor
includes assessment of functional tasks such as
writing, simulated feeding (although not as
applicable if able to observe actual eating as
mentioned above), picking up objects of various
size and weight. This would help me to narrow
down which areas are of the most concern and
which symptoms of PD are impacting them the
most.
Revised 1/9/17
4. vision – (possibly the Motor-Free Visual
Perceptual Test (MVPT 3) – d/t it eliminating the
need for motor abilities, which may help to hone
in on what deficits are actually limiting his visual
performance, thus making the test results more
reliable for Charlie)
5. mental health screen
6. SAFER-HOME – a Home-Evaluation to
be performed in the client’s home before he is
approved for d/c to live independently at home
-3
15. CPT Evaluation Code: Justification
Page 14 of 22
Charlie already has B cataracts, but the amount
of visual obstruction is currently unknown. I
would want to perform a vision test to determine
how his cataracts may be negatively affecting his
performance and participation in ADLs, IADLs,
and desired occupations, as well as determine if
there are any safety concerns related to the
severity of the cataracts.
To address possible depression commonly
associated with PD – I would possible (likely)
refer for Charlie to seek additional services – i.e.
psychologist. He has likely had a difficult few
years – between losing his wife, having an
increase in PD symptoms, and becoming less
independent d/t symptoms, I think his mental
health may be at risk for depression. I also
wonder if a family therapy session would be
beneficial to help Charlie and his daughter
become on the same page about his dx, prognosis
and current ability levels.
6. Charlie is anticipated to d/c to living
independently in his home after his stay in
transitional rehab, therefore, it is imperative that
the rehab team do an evaluation of his living
environment to make suggestions for any
modifications or adjustments that need to be
made at this time, and also what other
modifications/adjustments would likely be
desired in the future as his PD progresses and
symptoms worsen. Additionally, Charlie broke
his wrist d/t a fall in his home, suggesting that
home modifications and suggestions of AE
would be very appropriate for him.
Revised 1/9/17
97166 – Moderate A review of medical history should require an expanded review
Complexity (moderate complexity) at this time; it may be beneficial to search
through previous records to assess if any changes or progression of the
PD has occurred. The assessment of occupational performance would
require a high complexity d/t the dx of PD likely affecting more than 5
performance deficits (especially motor-related performance skills). The
level of clinical decision making required for this case is of moderate
complexity – more specifically, Charlie will require some more in-depth
assessments to ensure that he can safely d/c to home after his 10-day
transitional rehab facility stay. Overall, this would result in a Moderate
Complexity coding for Charlie at this time.

16. Projected Outcomes: Type of Outcome

1. Increase occupational participation in ADLs and IADLs Maintain
2. Maintain motor

17. Resources and Team Members

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- Charlie is the most important member of his treatment team.
- Charlie’s family (daughter Lola, and any other family that hasn’t been mentioned)/caregivers (if
any exist)
- PT, SLT and the Rehabilitation doctors overseeing Charlie’s rehabilitation
- Charlie’s physician/surgeon that fixed and casted his wrist (possibly important for precautions)
- Possibly psychologist – to further address any depression and/or psychosis that Charlie may
experience d/t his PD dx.
- Pharmacy/Nursing – to help evaluate and adjust any PD medications that Charlie may be taking –
and most importantly, utilize these providers to plan for and monitor on/off cycles of the
medication to be more productive with therapy.
- Social work – possibly to further advocate for patient about needs – possibly help educate
family/caregivers on top of other disciplines also doing this.

- This is a link to the American Parkinson Disease Association (APDA) – this particular webpage
is a resource for finding Nationwide chapters that provide PD support group, and other
opportunities for PD: https://www.apdaparkinson.org/community/

- This link is to the Michael J. Fox Foundation – this would be beneficial if client or family is
interested in current research that is being conducted to aid in PD care/treatment (it may not be a
comprehensive list – it may be influenced by what the foundation is supporting/helping to fund)
https://www.michaeljfox.org

18. Intervention Plan

Barriers Supports
- It is unclear what type of support system Charlie will have - Charlie’s motivation to return
once d/c to home – his daughter seems to consider his home upon d/c after10 days in a
level of functioning considerably lower than it likely is at transitional rehab facility -
this time. hopefully this will make his
- PD is a degenerative disease, so symptoms and abilities return to home (if appropriate),
will continue to worsen with time/progression of the as safe as possible.
disease. - On/Off cycles of PD medication
- Limited funding through Medicare to receive necessary – scheduling/functioning during
services. tasks during cycles
- His mental health status (likely experiencing depression) - He has a daughter who at least
may impede his success and independence in occupational came to the hospital to see him;
performance and participation in daily and/or meaningful are there any other
tasks. children/family/ caregivers?
- His dx of B cataracts will be a barrier to accurate
performance in some ADL and IADL tasks.
- On/Off cycles of PD medication – scheduling/functioning
during tasks during cycles
-
Goals Practice Model for each goal
1. LTG:

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 PEO, Rehabilitation
Within LOS, client will shower with Mod I, while utilizing
AE.
1a.STG: Motor Control/ Motor Learning
Within 5 days, client will independently transfer to and from
shower chair, utilizing controlled movement strategies
(rocking) with supervision for safety.

1b.STG: Rehabilitation
Within 5 days, client will cover cast on his LUE with Min A PEO
and utilizing AE, prior to showering to maintain cast
precautions.

2. LTG: Motor control/motor learning

Within LOS, client will I don button down shirt utilizing AE.

2a. STG: Within 5 days, client will lace shirt on arms and Motor control/motor learning,
around back with min A and utilizing compensatory Rehabilitation
strategies.

2b. STG: Within 5 days, client will I button a button on a shirt Rehabilitation, PEO
utilizing AE.

3. LTG:
Within LOS, client will I dress lower body while in an Rehabilitation, Motor
unsupported seated position, utilizing balance techniques and Control/Motor Learning
AE.
3a.STG:

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 Within 5 days, client will increase speed/efficiency while PEO, Rehabilitation, Motor
dressing LB, utilizing compensatory strategies for the Control/Motor Learning
bradykinesia and tremors, as observed by decreasing the time
required to dress LB on day 1 by at least 5 minutes.
3b. STG: Rehabilitation, Motor Control/Motor
Learning
Within 5 days, client will I don/doff socks and shoes with Min
A, while in a supported seated position.

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19. Treatment Sessions: Plan for first two 45 minute treatment sessions:
1. What will you do? Identify Approaches Based on which goal(s)?

Page 19 of 22 Revised 1/9/17

For this tx session, I would work on teaching and Prevent, 1a – Within 5 days,
beginning to implement how to use controlled establish/restore client will
movements (such as rocking back and forth) to the independently transfer
benefit of the individual (in this case, using the rocking to and from shower
as a way to initiate the movement of standing by chair, utilizing
increasing body momentum forward) when transferring controlled movement
onto and off of the shower chair Charlie has been using strategies (rocking)
in the hospital. The very first thing I would want to do, with supervision for
is observe how Charlie has been getting on/off of the safety.
shower chair, and see how much assistance and what
type of assistance he is currently needing to perform the
task in this way. Then I would begin to talk to Charlie
about which parts of this transfer he feels are the most
challenging for him, and would then go into a
conversation with him about what our body does and
needs to do in order to safely stand or sit on the shower
chair (i.e. tucking our feet somewhat under us, heads
and shoulders coming forward will help to naturally
raise the bum, pushing down off of whatever surface
you are rising from, and reaching back before sitting on
a surface to use arms to lower self-down instead of
plopping self-down. The beginning of this session will
be a bit of observation, a lot of discussion and
exploring which parts are challenging for Charlie, and
then attempting (multiple times if possible) to use the
general suggestions mentioned above. After Charlie
has a chance to try these basic and general transfer
guidelines a few times, understanding the general
suggestions and when to use them, THEN we will
move on to teaching about how to use the controlled
movement of rocking forward and backwards, shifting
the body weight forward and backwards, to create
enough momentum to begin lifting the bum off of the
sitting surface. At all times, the therapist should be
doing at least CGA for safety reasons. Begin these
transfers on a hard, stable chair with arm rests and that
is a good size for Charlie’s body size/type. If he
becomes more successful on this chair, then transition
to other surfaces (such as the shower chair or softer
recliner chair) practicing the same movement. All the
while, I would be explaining that PD often causes the
individual to have difficulty initating movements
voluntarily, but that this movement has been show to be
successful for others with PD.

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Charlie will likely become tired throughout this activity
– it is important to take many rest breaks, not over-
exerting him to the point of fatigue; avoid fatigue! If
he gets tired, then I can continue to demonstrate and
have discussions about what to do and when to rock
and how far/long you should rock.. things to look for
and how to react to them.

His sitting and standing balance is likely also

compromised or weakened, so remain aware of this and
adapt the task as necessary.

And ALWAYS use a gait belt!

2. What will you do? Identify Approaches Based on which

goal(s)?
For this tx plan, I will be focusing on LB dressing, but Preparatory activity,
will begin with an AROM exercise as a preparatory Prevent, Within 5 days, client
task to increase the mobility of joints to allow for establish/restore will I don/doff socks
bending at the hips/knees and reaching and pulling to and shoes with Min A,
don pants, socks and shoes (although Charlie prefers while in a supported
slippers). seated position.

For the preparatory AROM, I will have Charlie sit in a Within 10 days, client
supported sitting position and perform some basic will I dress lower body
AROM movements – flexing shoulder, elbow, wrist, while in an
fingers, abd and adducting shoulder and fingers, unsupported seated
extending elbows and wrist, fingers. If Charlie is open position, utilizing
to it, I would put on some music with a beat to try to balance techniques and
give Charlie’s body a tempo (which has been shown to AE.
be beneficial for PD) to keep while doing the AROM
(preferably music that Charlie enjoys) – if this activity
goes well, we could create a dance that Charlie could
dance to everyday – if he doesn’t like music or dancing
however, this would not be appropriate. I would also
have him do some simple AROM of his legs (hip
flexion, knee flexion, knee extension, ankle dorsi and
plantar flexion), allowing him to use self- performed
PROM if needed (I would educate him on all of the ifs
and hows of doing it safely and effectively).

After we are all loose in the joints, I will have Charlie

show me how he has been attempting to don/doff pants
and underwear – providing suggestions when
appropriate, but mostly observing the first time

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through. Then I will provide him with AE (likely a
reacher, unless grip is too poor – then a dressing stick)
and instruct how to get elastic waist band pants fed onto
his feet, how to use the reacher to pull it up as far as
possible, and when to grab, pulling the rest of the way
with his hands (repeat with underwear – assisting with
standing as this is not the focus during this session).
After the pants, I will introduce him to the sock aid and
have him practice feeding his sock onto the aid and
fishing his foot into sock, all while in supported seated
position and remaining aware of his balance. Then, if
willing have him attempt putting shoes on – possibly by
crossing foot over opposite knee.

If there is time, we may move on to learning UB

dressing techniques, if not, then I would just help him
don his shirt.

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