Home exercise program

1. and family will report participation in home exercise program activities a minimum of
days per week, for consecutive weeks, as an adjunct to skilled physical therapy
intervention and in preparation for independent home management upon discharge.

2. Caregiver will verbalize understanding of 3 developmental positions and/or

stimulation activities in preparation for development progression.

Stretching
Torticollis
1. will demonstrate equal active and passive cervical range of motion in right and left
sidebending, to at least 40 degrees, with a FLACC pain score of less than 2/10, on two
consecutive visits, in order to allow age appropriate midline orientation for acquisition of gross
motor skills.

2. will demonstrate equal active and passive cervical range of motion in right and left
rotation, to at least 80 degrees, with a FLACC pain score of less than 2/10, on two consecutive
visits, in order to allow age appropriate midline orientation for acquisition of gross motor skills.

Ankle
1. will demonstrate symmetrical bilateral ankle dorsiflexion on right and left sides of 30
degrees or more, in passive range of motion, on two consecutive visits, in preparation for
standing and weight bearing gross motor skills.

Hamstring
1. will display a bilateral heel to ear angle of 75 degrees or better, in two consecutive visits,
for improved hamstring flexibility necessary for participation in age appropriate gross motor skills.

Reflexes
Tonic Labyrinthine
1. will exhibit integrated tonic labyrinth reflex using a decreased arching pattern with
functional movements 75% of session time, 3/4 sessions to prevent abnormal movements
patterns with acquired gross motor skills.

Protective extension
1. will demonstrate bilateral protective extension forward when tilted from sitting, by
extending bilateral upper extremities and bearing weight symmetrically on open palms to prevent
falling, with trunk and head in midline, in 4/5 trials, for improved safety during exploration of
environment.

2. will demonstrate protective extension laterally, to the right and left, when perturbed from
sitting, by extending the ipsilateral upper extremity and bearing weight on an open palm to break
her fall, in 4/5 trials, for improved safety during exploration of environment.

3. will demonstrate bilateral protective extension backwards when tilted from sitting, by
extending bilateral upper extremities and bearing weight symmetrically on open palms to prevent
falling, with trunk and head in midline, in 4/5 trials, for improved safety during exploration of
environment.
ATNR
1. will demonstrate a fully integrated asymmetrical tonic neck reflex by evidence of no arm
movement with rotation of head, in 4/5 trials, in preparation for age appropriate rolling and
mobility.

2. will demonstrate a fully integrated ATNR response, as evidenced by no bilateral arm

movement with passive cervical rotation in supine, to the right or left, in 4/5 trials, for age
appropriate reflex integration to allow for continuing development of gross motor milestones.

Landau
1. will demonstrate age appropriate Landau response while in prone suspension, with head
and hips above horizontal plane and trunk extended, using symmetrical body posture, in 4/5
trials, for age appropriate neurological development and trunk strength.

Prone Goals
Prone on Elbows
1. will maintain prone on elbows with symmetrical weight bearing on bilateral elbows, with
head up at least 45 degrees at midline, for a duration of at least 5 seconds, in 4/5 trials, for
improved exploration ofenvironment and interaction with family members.

Prone Press Up
1. will push up on extended arms in prone, with open palms, complete elbow extension,
and trunk and head in midline, with head up at 90 degrees, for a duration of 10 seconds, without
assist or loss of balance, in 4/5 trials for improved exploration ofenvironment.

Quadruped
1. will attain and maintain quadruped position with midline trunk and head for a minimum of
5 seconds, without assistance or arching, in 4/5 trials, for improved interaction with family
members and exploration of environment.

2. will raise shoulders and buttocks to bear weight on hands and knees for at least 5
seconds while rocking back and forth a minimum of 2 cycles, with trunk and head in midline, and
head lifted 90 degrees, in 4/5 trials, for improved exploration of environment.

Supine Goals
1. will bring right or left hand to mouth in midline when supine 100% of the time in
preparation for self comfort, and developmental activities.

2. will grasp both feet with hands while in supine and play with them for a minimum of
3 seconds, in 4/5 trials, for improved self exploration and trunk strength in preparation for age
appropriate mobility.

3. will grasp both feet with hands and bring to mouth while in supine and play with
them for a minimum of 3 seconds, in 4/5 trials, for improved self exploration and trunk strength in
preparation for age appropriate mobility.

4. will reach up in supine with both hands midline for a toy within 5 seconds of presentation,
while maintaining midline head and body position, in 4/5 trials, for improved midline orientation
and more independent exploration during age appropriate play.

5. will visually track a toy throughout full symmetrical, painfree, active cervical range of
motion while in supine, in 2/3 trials, for improved access to toys andenvironment.
Rolling
1. will roll from supine to sidelying, right and left, with opposite arm crossing midline, by
leading with hips or shoulders to utilize an age appropriate segmental roll, in 4/5 trials, for
improved independent floor mobility.

2. will roll supine to prone, over right and left sides, utilizing a segmental pattern, without
arching, and no assist or facilitation, in 4/5 trials, for improved independent floor mobility and
exploration of environment.

3. will roll prone to supine and supine to prone, with an age appropriate segmental pattern,
over right and left sides, independently and without arching, in 4/5 trials, for improved
independent floor mobility.

Crawl
1. will maintain commando crawl on belly a distance of 10 feet to get a to using
reciprocal pattern, in 2/3 trials, in order to engage in more age appropriate functional mobility.

Creep
1. will creep in quadruped using a cross lateral or reciprocal pattern, to cover a distance of
at least 10 feet, with symmetrical and midline trunk and head positioning, without loss of balance
or assistance, in 4/5 trials, for improved independent floor mobility and interaction with family
members.

Sitting balance
Independent Sitting
1. will maintain sitting balance with midline posture of trunk and head when placed for 8
seconds, with or without upper extremity propping, in 3/5 trials, to allow for interaction with family
members, environment, and toys via age appropriate gross motor skills.

2. will demonstrate independent sitting with midline posture for 60 seconds, with bilateral
upper extremities free to play with a toy, without assistance or loss of balance, in 2/3 trials, for
improved postural control necessary for safe exploration of environment.

3. will reach forward 12 inches from sitting to retrieve a toy, and return to midline and
maintain sitting for 30 seconds without loss of balance or need for support, in 4/5 trials, for
improved interaction with family members.

Ring Sitting
1. will independently ring sit for a duration of 30 seconds with at least one hand free to
reach for a toy in 2/3 trials for continued interaction with environment.

2. will prop sit with open hands weight bearing on floor in front, head in midline without
external assistance for a duration of seconds in 4/5 trials for improved sitting balance and
ability to interact with environment.

3. will be able to ring sit with minimal assistance at lower trunk while maintaining head in
midline for 15 seconds, 3/4 trials, in order to interact with environment.

Supported Sitting
1. will hold trunk off of legs in at least a 30 degree angle for 5 seconds while in
supported sitting, in 2/3 trials, for improved exploration of environment and interaction with
family members.
Pull to sit
1. will pull to sit with equal bilateral upper extremity activation and midline head with full chin
tuck, in 4/5 trials, for improved midline orientation and strength necessary to progress to more
age appropriate gross motor skills.

2. will pull self up to sit from supine on the floor using a chair or other furniture for support,
without rolling to prone, in 3/4 trials, in preparation for more advanced and age appropriate gross
motor skills.

Cruise
1. will cruise to the right and left 4 steps each, while standing and holding onto a small
bench or table, without scissoring lower extremities or falling, no assistance, in 2/3 trials, for
improved independent functional mobility.

Tall Kneeling
1. will maintain balance in tall kneeling for 5 seconds while rotating head, without hands on
support surface, in 3/4 trials, for improved trunk control necessary for advancing to more age
appropriate gross motor skills.

2. will pull to stand at a support surface, via half kneel, over right and left lower extremities,
without loss of balance, in 4/5 trials, for improved independent functional mobility and exploration
of environment.

Sit to Stand
1. will stand up from a seated position on the floor, without assistance, and without turning
body more than degrees, in 3/5 trials, for improved independence with transfers and
exploration of environment.

2. will lower to sit from standing without falling, using no upper extremity support or external
assistance, in 4/5 trials, for improved lower extremity strength and decreased extensor tone.

Squat
1. will squat to floor from steady standing position to retrieve a toy and return to standing
without loss of balance or upper extremity assistance in 4/5 trials to enable participation in age
appropriate functional mobility.

Balance
Standing
1. will maintain independent standing balance once placed for a minimum of 5 seconds,
without a support surface, in 4/5 trials, in preparation for more age appropriate balance and gross
motor skills.

2. will stand independently for 5 seconds, by freeing hands and body from support surface
and maintaining upright standing without support, in midline posture, in 4/5 trials, for improved
balance and functional mobility.

Single leg
1. will balance on one leg while standing on a balance beam with eyes closed, for 5
seconds or more, right and left sides, with hands on hips, in 4/5 trials, for improved age
appropriate balance.
2. will balance on one foot for a duration of seconds each foot, with hands on hips,
without upper body swaying more than 20 degrees, in 4/5 trials, for improved age appropriate
balance during lower body dressing and ADLs.

Balance Beam/line
1. will walk forward on a 2 inch line for at least 8 feet, keeping one foot on the line, in 3/5
trials, for improved age appropriate gait pattern and safety while walking.

2. will walk forward 8 feet with both feet on a line, without stepping off, with hands on hips,
without heels touching toes, and without swaying more than 20 degrees, in 4/5 trials, for improved
age appropriate balance and functional mobility to safely negotiate small spaces.

3. will walk on a 4 inch wide balance beam for a length of 8 feet, without hand held
assistance, without stepping down, in 4/5 trials, for improved balance and ability to ambulate with
narrow base of support.

Tip Toes
1. will balance on tip toes with arms overhead for seconds, in 3/5 trials, without
moving his feet for increased participation in age appropriate play.

Ambulation
Forward
1. will take 4 alternating steps forward, with support around trunk, using equal weight
shifting, without collapse or loss of balance, in 4/5 trials, for improved exploration of
environment.

1. will ambulate with an age appropriate pattern for feet, with reciprocal arm swing,
neutral lower extremity alignment and base of support, without assistance or verbal cueing, in 3
consecutive treatment sessions, for improved functional mobility independence and safety.

2. will ambulate with an age appropriate pattern and cadence without falling to cover a
distance of feet in minutes, in 2/3 trials, in order to safely cover school-related
distances without falling or getting left behind from a group of peers.

3. will ambulate feet without assistance using an age appropriate pattern, neutral
width base of support and correct heel-toe gait pattern without falling or loss of balance, in 3/5
trials, for improved safety and independent exploration of his environment

4. will walk unaided for steps without losing balance, falling, or sitting, in 3/5 trials, for
improved independent exploration of environment.

5. will take 8 alternating steps forward with one hand held assist, and no loss of balance, in
4/5 trials, for progression toward independent age appropriate functional mobility.

Backward
1. will walk backward 5 steps, with or without a pull toy, without loss of balance or
assistance, in 4/5 trials, for improved balance and age appropriate safety in environment.

2. will walk backward 10 feet with good trunk control, using a normal stride with no loss of
balance in 2/3 trials to allow participation in age appropriate play and home mobility.

Lateral
1. will walk sideways 5 steps with good trunk control, without crossing legs, with no loss of
balance in 2/3 trials to allow safe negotiation of narrow spaces and home mobility.
Incline
1. will independently ambulate up a 30-45 degree incline ramp for at least 3 feet,
demonstrating increased lower extremity strength and eccentric control with balance, in 4/5 trials,
for safe ambulation within the community.

Obstacles/Uneven Terrain
1. will ambulate around a room of obstacles forminutes, without falling more than
times, in two consecutive treatment sessions, to improve safety awareness for independent
negotiation of variable surfaces in community settings.

2. will ambulate on outdoor terrain with uneven or rough surfaces using an age appropriate
gait pattern and cadence, to cover a distance of 150 feet, without assistance, verbal cueing, or
loss of balance, in 4/5 trials, to demonstrate age appropriate safety with functional mobility.

Stairs
1. will ascend/descend a full flight of stairs with hands free to carry a small object, in 2/3
trials, for improved independent community mobility and safety.

2. will walk up and down an entire flight of stairs with a reciprocal pattern, without the use of
a railing or assistance, without loss of balance, in 2/3 trials, for improved functional mobility
independence.

3. will ascend and descend a full flight of stairs using reciprocal pattern with no greater than
1 hand on the railing and the other free to carry items in 2 consecutive visits, in order to enable
safer and more age appropriate navigation of her environment.

4. will creep up and down 4 stairs with reciprocal pattern on hands and knees, in 2/3 trials,
for more age appropriate and safe community mobility.

5. will walk down 4 steps with only one hand finger hold support with reciprocal or step-to
pattern without sitting or collapsing to floor in 3/4 trials to allow greater independent exploration of
environment.

Bike
1. will ride a bike with no training wheels for minutes without tipping, falling, or
stopping; in 3/4 trials, to allow participation in age appropriate peer play.

2. will ride a standard bicycle with no training wheels feet on 2 consecutive visits with
proper form and no loss of balance to demonstrate improvements in functional strength and
coordination and enable participation in age appropriate play.

Jumping Jacks
1. will perform 5 jumping jacks, with appropriate upper and lower extremity coordination,
without dissociation or falling, requiring only demonstration and minimum verbal cues for
assistance, in 4/5 trials, for improved coordination necessary to participate safely in peer play and
school activities.

Sit ups
1. will perform sit ups in 30 seconds, without compensatory strategy or use of upper
extremities for assistance, using therapist as anchor for feet, in 2/3 trials, for improved core
strength necessary for age appropriate postural control.
Push Ups
1. will perform knee push-ups with appropriate trunk control, in 3/5 trials, for
improved participation in peer play.

Jumping

Forward
1. will jump forward inches on one foot, without other foot touching the floor or loss of
balance, with right and left sides, in 4/5 trials, for improved participation in peer play.

2. will jump forward inches or more using a 2 footed take-off and landing, without
assistance or loss of balance, in 4/5 trials, for improved participation in age appropriate peer play.

Down
1. will jump down from a bench or step at least inches high, without assistance or loss
of balance, using a 2 footed take-off and landing, in 4/5 trials, for improved lower extremity
strength during peer play.

Lateral
1. will perform lateral hopping on bilateral lower extremities a total of hops to each
side with feet together in 3/4 trials for improved coordination to enable to participate in age
appropriate play activities.

Hop
1. will perform consecutive single leg hops on right or left leg in seconds,
without assistance or loss of balance, in 4/5 trials, for improved participation in age appropriate
peer play.

2. will jump up 2 inches or higher, using a 2 footed take-off and landing, without loss of
balance or assistance, in 4/5 trials, for improved participation in peer play.

Throwing
Underhand
1. will throw a ball underhand to hit a 2 foot target a minimum of feet away, in
trials, for improved participation in age appropriate peer play.

2. will throw a tennis ball underhand 7 feet with age appropriate mechanics and trunk
rotation, 4/5 trials in 2 consecutive visits to enable to participate in age appropriate peer
play.

Overhand
1. will throw a tennis ball overhand to hit a target feet away at eye level with
proper throwing mechanics, hitting the target 4/5 trials in 2 consecutive visits to enable to
participate in peer play and physical education.

2. will throw a tennis ball overhand 7 feet with age appropriate mechanics and trunk
rotation, 4/5 trials in 2 consecutive visits to enable to participate in age appropriate peer
play.
Catching
1. will catch an ball thrown from 5 feet away using 2 hands, without cradling it to
chest, in 4/5 trials, for improved participation in peer play.

2. will catch a bounced tennis ball with hand in 3/4 trials in order to demonstrate
improved coordination for participation in age appropriate gross motor activities.

3. will catch a ball by presenting both arms extended directly in front, securing the ball by
bending arms toward the chest, in 3/5 trials, for improved peer play.

Kicking
1. will kick a stationary ball using opposing arm and leg movements so that that it travels in
the air for at least 3 feet in 4/5 trials to improve participation in peer play.

2. will kick a stationary ball forward 6 feet, without it deviating more than 45 degrees from
midline, and without loss of balance, in 4/5 trials, for improved age appropriate play skills and
single leg balance.

3. will kick a stationary ball so that it travels at least 3 feet forward without loss of balance in
4/5 trials in order to participate in age appropriate play.

Skipping
1. will skip with proper reciprocal form feet without loss of balance or rhythm to
demonstrate improvement in whole body coordination as well as lower body strength and enable
participation in peer play.

2. will skip 8 steps maintaining balance, using opposing arm and leg movements, and
alternating feet, without verbal cues or loss of balance, in 4/5 trials, for improved participation in
age appropriate play.

Running
1. will run feet with age appropriate form and reciprocal arm swing without
asymmetries, in 3/5 trials, for improved participation in peer play.

2. will run feet in seconds or less, with age appropriate gait pattern, neutral base
of support, and reciprocal arm swing with trunk rotation, in 2/3 trials, for improved participation in
peer play.

3. will run forward at least feet with good body control and age appropriate arm swing,
without falling, in 2/3 trials, for improved lower extremity strength and age appropriate dynamic
standing balance.

Transfers
1. and family will report transferring into and out of car with no more than minimal assist
from family members for two consecutive weeks, for improved safety and age appropriate
functional mobility.

2. and family will report completing transfers in and out of the tub with only supervision from
an adult for two consecutive weeks, for improved age appropriate independence with mobility.

Behavior
1. will participate in minutes of skilled physical therapy activities with no more than
verbal cues to redirect attention, for two consecutive treatment sessions, for improved
independent participation to increase productivity of sessions.

2. will participate in minutes of physical therapy activities with only moderate

assistance needed to redirect him, no more than 10 times, in two consecutive sessions, for
improved participation and productivity in sessions as well as in school.

Bracing
1. will demonstrate ability to don and doff selected braces with equal or less than 25%
assistance, for 3 consecutive weeks per parent report, for improved independence with modified
functional mobility.

2. will tolerate regular wear of appropriate selected braces, without adverse skin reaction,
per parent report for 3 consecutive weeks, as an aid in functional mobility independence.