Summary: Ali is now two years old and continues to make progress towards her goals. She has increased muscle tone and limitations in fine motor coordination and self care skills.
1. Reach to cause and effect toy with 80° right shoulder flexion: met
2. Reach to cause and effect toy with 80° left shoulder flexion: met
3. Grasp 1 to 2" cube or toy using a radial digit grasp: improved but not met
4. Use both hands together when offered a light weight 12" toy held to her fingers: not met
1. Finger feed 6/6 Gerber Puffs or other soft finger foods independently
A. Finger feed 3/6 Gerber Puffs with moderate assist
B. Finger feed 4/6 Puffs with minimum assist
2. Spoon feed 2 ounces of thick puree with moderate assist
A. Spoon feed 1 ounce of thick puree with maximum assist
B. Spoon feed 4 bites of thick puree with moderate assist
4. Independently hold a light weight 10" toy with both hands
A. Hold a 10" light weight toy with both hands with minimum assist
General: Ali is now two years old and scheduled for twice weekly occupational therapy. She continues to make progress towards her goals.
Caregiver Concerns: Her grandmother notes that although Ali now tolerates taking a bath, it has become increasingly difficult to support her in the tub. Ali leans towards the right when sitting in her car seat and her grandmother would like her to be safely supported when in the car. She also wants Ali to be more successful feeding herself.
Range of Motion: Ali's upper extremity range of motion is within normal limits.
Muscle Tone: Ali has increased muscle tone in bilateral upper extremities. All shoulder motions, forearm supination, and elbow extension are tight at end ranges. Although she will open her hands, her thumbs are often in her palms in the left more than right.
Fine Motor Coordination: Ali is demonstrating increased curiosity about her environment and is using her hands more frequently to explore and play with toys. She has met her goals of reaching with her right and left arms to 80° or more to play with cause and effect toys. Although she is beginning to visually focus and occasionally track moving objects, her vision is not consistent or functional. She frequently relies on her auditory and tactile senses to relate to her environment. Ali's ability to grasp and release is restricted by flexor tone in her hands and thumbs. Although she volitionally opens her hands for toys, she lacks complete active thumb abduction and opposition for more refined and age appropriate grasp and release patterns. With her right hand, she has a functional lateral pinch but not the graded control and coordination to finger feed independently. With her left hand, she pinches with her index finger pad to the dorsum of her thumb IP. Ali is not yet using both hands together to grasp and explore large toys.
Activities of Daily Living. Ali feeds herself Gerber Puffs and other finger foods with maximum assist. She is normally handed finger food, but is starting to occasionally reach to it on her tray. She often gets the food near her mouth but has difficulty consistently targeting to her mouth and coordinating the release of the Puff into her mouth. Ali was placed at a table in a Snug Seat to assess her abilities to use a spoon. She was given a bite of chocolate pudding and then the spoon was placed into her hand. Once the spoon is loaded for her, Ali brings it towards her mouth. She was able to target her mouth with minimal assist for a couple of bites, but overall needed hand over hand assist to get the food loaded and into her mouth. Ali is dependent for the remainder of her self care needs.
Recommendations: Occupational therapy to continue with twice weekly visits to
1. Work on the above goals
2. Obtain bath chair, car seat, and feeding chair
3. Monitor range of motion, fine motor coordination, and self care skills
4. Update her home stretching and activity program
5. Consider Joe Cool type of splints to help her open her hands for continued
advancement of fine motor and self care skills