Reaching is a Fundamental Activity that Promotes Development and Independence with Everyday Activities

The Importance of Reach and How Therapy can Help 

The ability to reach may not be as simple to individuals with certain injuries, disabilities or deficits. For example, an individual with a rotator cuff tear, may be unable to reach overhead to wash hair.  Someone who is recovering from a hip replacement is restricted in his movements and is unable to bend past the waist to donn and doff shoes.  These individuals are often referred to a physical and/or occupational therapist.  Reaching requires multiple skills that we can address as healthcare professionals.

 

Tying Together Functional vs Nonfunctional Reaching

Functional reaching is necessary in order to complete activities of daily living.  We reach on a daily basis.  We reach to get dressed, bathe, cook, clean, etc… the list goes on and on.  

An example of non-functional reach is range of motion.  Range of motion is a key component in being able to reach.  With limited or no range of motion, an occupational therapist can suggest adaptive equipment such as a long handled reacher, dressing stick, or shoe horn.

Preparatory activities can also be considered as non-functional reaching. Preparatory activities for reaching can help to achieve the basic skills required for the more advanced functional tasks.  For example, if a patient has a goal to reach overhead to place dishes away into the cabinet, a preparatory activity could be simply reaching overhead and then progression to reach overhead to tap a particular target.

Functional reaching goals require both non-functional and functional reaching activities.  For example, in order to donn/doff socks and shoes, an individual may complete reaching towards the ankle to promote flexibility and practice sequencing.

 

PT and OT Approach to Reaching

Physical and occupational therapists possess the skills and knowledge to assess anatomy and function.  The shoulder complex is composed of four joints including the glenohumeral, sternoclavicular, acromioclavicular, and scapulothoracic joints.  Range of motion in all four joints is required for coordinated movements of the shoulder.  Reaching also requires coordination and movement from the elbow, hand and wrist.

Reaching can be addressed by both physical and occupational therapists.  Physical therapists can facilitate reaching activities as part of balance, strengthening and coordination.  Whereas occupational therapists may facilitate reaching as a goal to complete ADLs. 

Physical and occupational therapists are trained in many of the same assessments that can be used for measuring reach and falls risk.  Both disciplines may assess range of motion in the upper extremity with a goniometer.  Range of motion of the shoulder, elbow, wrist, and hand can all be assessed to determine the best outcomes for reaching abilities.

The Functional Reach Test measures reach to determine balance problems in older adults. A score of 6 or less indicates a significant increased risk for falls. A score between 6-10 inches indicates a moderate risk for falls.

Physical therapists may use the BERG Balance Scale, which involves reaching components.  Specifically, parts 8 and 9 - Reaching forward with outstretched arm and retrieving object from floor.  Occupational therapists may also use the BERG Balance Scale - just be sure only one discipline uses this measure if both are treating the same patient in order to avoid duplication of services.

A fourth assessment is the Back Scratch Test.  The purpose of the Back Scratch Test is to measure shoulder range of motion.  To facilitate this test, the patient should be positioned in standing. He/she will be instructed to reach over the head and then down the back, with palm facing the body.  Then reach the other hand behind the back with the palm facing out and reach up the back as far as possible. The goal of the test is for the tip of the middle fingers to touch or overlap.

Trunk mobility, hip flexion and ankle dorsiflexion are also important areas to assess with reaching.  These body parts are key in offering stability while reaching.  

Depending on how you use reaching in your treatments, reaching can be used as a therapeutic exercise, therapeutic activity, cognitive skill, sensory integration, or neuromuscular reeducation.

 

Any Population Can Benefit from Reaching Activities

Pediatrics, young adults, adults, and older adults all need the skills for reaching.  Reaching is a major milestone for infants and should be addressed early on.  A baby can begin reaching as early as 3 months, although it is more common around 4 months.  Reaching is essential for play and developing motor skills needed to perform daily activities.  

For adults, reaching is essential for maintaining, restoring, or achieving one’s independence.  Without the ability to reach, one will require dependence on a caregiver.  Losing the ability to reach impacts multiple areas of our daily lives, which could lead to a negative impact on one’s quality of life.

 

Billing for Functional Reach

To bill for functional reaching activities you can use CPT code 97530 for therapeutic activities. Therapeutic activities include interventions that use whole-body movement to gradually improve functional performance, such as bending, lifting, carrying, reaching, catching, transfers, and overhead activities.

You may also include reaching activities during ADL training such as reaching for utensils during self-feeding activity or reaching for supplies for grooming.  In this case, you will use code 97535 - Self-Care.  This code focuses on the performance of ADLs, including teaching compensatory strategies, use of adaptive equipment, and education on health management and home modifications.

For non-functional reach, you may use CPT code 97110 for therapeutic exercises.  This code is used for a therapy procedure using exercise to develop strength, endurance, range of motion and flexibility.  It is important to gain these skills for functional use of certain body parts required for functional reaching.

Another CPT code to use for addressing reach is 97112 – Neuromuscular Re-education.  This code is used when a therapist facilitates re-education of movement, coordination, balance, posture, and proprioception.  

If manual therapy is warranted, you will use CPT code 97140.  Manual therapy techniques include mobilization, manipulation, lymphatic drainage, and manual traction.  A therapist may use manual therapy prior to functional activities in order to improve functional performance. 

Trust your clinical judgment to choose the right treatment diagnosis that best matches the skill you are providing. 

 

Evidence-Based Research

Kelly Anderson; The Relationship Between Self-Reported Hand Use and Movement Efficiency. Am J Occup Ther July 2015, Vol. 69(Supplement_1), 6911510138p1. doi: https://doi.org/10.5014/ajot.2015.69S1-PO4092

Results suggest that directness of movement during a reach-to-target, but not movement smoothness, is significantly related to self-reported hand use after stroke.

Susan E. Fasoli, Catherine A. Trombly, Linda Tickle-Degnen, Mieke H. Verfaellie; Effect of Instructions on Functional Reach in Persons With and Without Cerebrovascular Accident. Am J Occup Ther July/August 2002, Vol. 56(4), 380–390. doi: https://doi.org/10.5014/ajot.56.4.380 

One clinical implication from this study is that internally focused instructions can contribute to slower and less forceful reach in adults with and without CVA. This research reinforces the need for therapists to consider their use of instruction during the evaluation and treatment of movement disorders.

During the internal-focus conditions, instructions directed the performer’s attention to the movements necessary for task completion (e.g., “apply pressure the outer foot” ) 

The externally focused instructions directed participants to focus their attention on task-related variables, such as the movement of the golf club or the center of the target These instructions appeared to emphasize the visual information available from the interaction with task objects.  Findings revealed significantly better motor performance and learning (exhibited by greater movement amplitude, higher accuracy, and less variability) in the external focus condition of both acquisition and retention trial.

 

Reaching/Grasping Adaptations for ADLs

Long-handled reachers

Dressing stick

Sock aid

Shoe horn

Long-handled sponge

Soap on a rope 

Universal cuff

Built-up utensils

 

Skills Needed and Addressed with Reaching

Upper Extremity Strength

Upper Extremity Range of Motion

Gross Motor Coordination

Motor Control

Sitting Balance

Standing Balance

Trunk Mobility

Hip Mobility

Rotation

Hand-Eye Coordination

Pincer Grasp

Grip Strength

Head Control

Depth Perception

Visual Motor Skills

 

Example Goals for Reach 

Part I - Measurable

Patient will increase score on functional reach test to 10 in order to...

Patient will increase L shoulder flexion by 20 degrees in order to...

Patient will increase R elbow extension by 5 degrees in order to...

Patient will improve Back Scratch test to -3 in order to...

Patient will increase dorsiflexion range of motion by 5 degrees in order to...

Part II - Specific and Patient-Centered

...retrieve soap for independence with bathing

...retrieve soap for independence with bathing

...retrieve clothing for dressing

...reach to LE to donn/doff socks and shoes

...open door

...reduce falls risk while retrieving mail from the mailbox

...clean body during toileting

...clean and dry body during bathing

...retrieve dishes for meal time

...put away groceries

...put away clothing in closet

...participate in card games with friends

...manage light switches in the home

...donn seat belt

...perform work duties including telephone use, typing, and using the fax machine

 

Graded Reaching Tasks

Reach outside of base of support

Decrease base of support in standing

Stand on uneven surface such as a balance pad or disk

Step with reaching task

Add wrist weights or reach for heavier items

Reach between objects

Reach over or under a threshold

Complete reach in multi-directions while weight shifting

Reach to retrieve object in one direction and place on surface in a different direction

Reach in single leg stance position

 

Sitting Reach Activities

Directional reaching activities (can promote forward, posterior, cross/diagonal and lateral reach)

Table top activities - rice bin, coin in slot, flower arrangements, utensil sort

Meal prep - stirring, lifting, moving items

Towel slides/wiping counter or table

Rolling ball on table to knock down cups

Stacking

Wrapping a present

Stuffing envelopes

Sorting

Planting seeds

Painting pottery

Donn/doff seat belt

Retrieve items on opposite side of the body

Wash and dry hands at sink

Tuck in shirt

Brushing hair

Hair styling

All of these activities can be upgraded to standing

 

Standing Reach Activities

Putting away dishes 

Empty or load dishwasher

Item retrieve in fridge 

Wipe counter

Fold towels

Wash and dry dishes

Organizing books on a bookshelf 

Make the bed

Mix ingredients

Meal prep 

Set table

Organize desk

Boxing

Dancing

PVC Pipe Building

Indoor gardening

Hygiene activities at sink (brushing teeth, washing hands, applying makeup, shaving)

Pinning pictures on a bulletin board

Hanging clothes on a clothesline

 

Supine Reach Activities

Reach to night stand

Retrieve to remote on side of bed

Set alarm clock

Dial # on telephone

Use call bell 

Reach to head board (ex. Remove post-its)

Up on elbows reaching for covers

Reaching for bed rail to complete bed mobility 

 

Pediatrics 

Sensory play

Washing vegetables and fruit

Assorting flowers

Picking up leaves

Towel slides with different textures of towels, cloth, etc

Finger painting

Digging through a sandbox to collect shells 

Play

Reach for and stack blocks

Reach for books

Page turning

Reach towards colors and visually appealing objects

Putting away toys

Reach and grab towards play gym or mobile

Petting dog or cat

Chalk drawing

Sports (volleyball, basketball, tennis)

Imagination/role playing

Kitchen play

Gardening

Shopping

Cleaning

Racing play cars

“Airplane”

Chores - making bed, putting away clothes and toys

 Building

 

Positions to Consider for Pediatric Play

Sidelying

Can improve core strength

Can improve UB strength

Coordination

Promotes crossing midline

Sitting

Promote core strength

Promote head control needed for self-feeding

Bilateral integration

Core rotation

Crossing midline

Prone/Tummy Time

Can promote neck and core strength

Head control

UB strengthening weight bearing in hands

Supine

Promotes crossing midline

Promotes UE ROM and strength

Promotes bilateral integration

Standing

Promotes dynamic balance

Promotes Endurance

LE Strengthening

Ankle ROM and stability

Kneeling

Can increase hip mobility

Increases knee flexion

Promotes proximal stability

Hip stability

Table Top/All 4's

Upper body strength and stability

Weight bearing in hands

Knee flexion

Core strength

 

Documentation Samples

Verbal cues to maximize range of motion while reaching into cabinet

Physical assistance at hips to stabilize patient while reaching outside of BOS

Tactile facilitation at hands to open wider to retrieve object

Visual cue placed near target to improve targeted reach due to decreased depth perception

Physical assistance of UE to provide stability and range of motion to reach towards object

 

References

http://www.hhvna.com/Functional_Reach_Test.pdf

https://www.brandeis.edu/roybal/docs/Berg-Balance-Scale_Website.pdf

https://clinicalportfolio.files.wordpress.com/2016/07/back-scratch-test2.pdf

https://www.americanmedicalcoding.com/cpt-code-97112/

https://www.codingahead.com/97530-cpt-code-description-guidelines-reimbursement-modifiers-example/

https://www.ama-assn.org/practice-management/cpt/cpt-code

https://www.aota.org/practice/practice-essentials/coding/interventions