Substitution Sheet

Diagnosis: Left CVA

Symptoms: Minimal active movement in RUE, high tone and severe in RUE and RLE,
minimal sensation on right side, severe expressive aphasia, and decreased STM that
limits safety during sit to stand/stand to sit transfers.
Current Functional Status:
Transfers: Client requires min A and verbal cuing to complete sit to stand
transfers.
Positioning prior to t/f: Client requires v/cing for proper body
mechanics including scooting to the EOB and and pushing off of mat to
stand. Client is dependant on OT to position RLE under BOS prior to
t/f. Clients husband uses a gait belt to assist with transfers so this is
the method I use (they bring the belt to therapy).
During t/f: Client primarily needs physical assistance during the first
15% of the t/f (v/c to lean forward, Mod A to get off mat initially, and
blocking RLE with my knees). She is able to stand independently after
this initial assistance.
Stand to sit t/f: Client req 1-2 v/cs to position back of knees against
mat and reach back to the surface she is going to sit on. Otherwise, she
will plop down w/c or on mat instead of slowly lowering herself
down.
Functional mobility:
Client completes functional mobility with CGA (gait belt) and use of
quad cane. She can ambulate from lab to apartment next door.
WBing activities:
Client is dependant on OT to open hand and place in paddle on mat
(use dycem to keep paddle in one place).
Seated: Client is able to complete seated functional reach tasks with
LUE towards right more affected side with facilitation of right elbow
extension.
Standing: Client is also able to tolerate standing x7 minutes during
functional reach tasks with RUE in WBing position on countertop.
While standing client req v/cing to maintain good posture and bear
weight bilateral through LE.
Reaching activities:
I have positioned clients RUE so that she can complete elbow
extension in a gravity minimized position. Client is dependant on OT
to extend elbow (concentrically), but is able maintain elbow extension
isometrically (x3 seconds) and bring back into flexion eccentrically.
Client requires extensive v/cing to facilitate and maintain isometric
and eccentric elbow flexion.
Precautions: Client is a fall risk.
Other: Clients husband attends all sessions to aid with t/fs and communication
barriers as needed.

Treatment Activities for next session:

1. Stretching/Mobilizing to facilitate good posture:
a. Make sure client is seated at the EOM with feet flat on the floor for
better balance.
b. Verbally ask client to sit up nice and tall. This should be sufficient to
get her to anteriorly rotate hips and extend thoracic spine. If not,
complete the stretches/mobilizations for these movements.
c. Stretch and mobilize scapula
i. Scapular depression
ii. Scapular adduction
2. Seated dynamic reaching while WBing through RUE.
a. Preparatory: Position right hand in paddle and prop up on phone
book underneath dycem. Place playing cards on clients left side and
position adjustable table on clients right side.
b. Activity part 1: Ask client to pick up cards with LUE and sort by suit
on the table. As client leans towards affected side, apply a
downward/forward force on right elbow to extend.
i. Grade up/down: Change height and distance of the table
c. Activity part 2: After client has sorted all cards, reposition table
directly in front of client but place out of reach (a good distance
away). Client will retrieve cards from table and place on mat, BUT will
come slightly off the mat to access the card on the table (like a squat
stand OR the initial 15% of a sit to stand t/f). Provide facilitation at
pelvis and RLE/knee and v/cing to use LUE to push off mat. Complete
repetitions until client reports fatigue (may only be 3-5x)
3. Standing dynamic reaching activity while WBing through RUE.
a. Preparatory: Assist client with sit to stand t/f and ambulation to
kitchen. Position clients RUE in WBing on countertop with dycem
and place items from shelf on countertop on clients right side.
b. Activity: Client will place items back into the cabinet with LUE while
WBing through RUE with facilitation via OT to extend elbow joint.
Encourage client to place weight equally through both LE.
4. Stretching/mobilization to facilitate shoulder flexion.
a. If client can achieve 90* of shoulder flexion passively after stretching,
then progress to activity #5.
5. Gravity minimized horizontal abduction and adduction of more affected RUE.
a. Preparatory: While seated at EOM, support clients RUE on table in
90* shoulder flexion. Place low friction furniture sliders underneath
pillow case to minimize resistance.
b. Activity: Ask client to complete horizontal abdution/adduction by
saying something like I want you to try to move your arm on the
table or wipe down the table with the pillow case.
i. Grade down: If client is unable to complete this motion in
gravity-minimized position, grade down to gravity assisted
activity. Secure right hand in paddle to back of chair and
position chair on phone books in gravity minimized. Ask client

to extend elbow concentrically. If she cannot, position R elbow

in extension and ask her to maintain position isometrically and
bring back to flexion eccentrically.
6. NOTES: Place a chair nearby while the client is standing. Take lots of breaks if
needed as the clients energy level fluctuates from session to session. While
completing t/fs quiz the client for understanding of body mechanics (where
should you put your hand? which direction should you lean etc)