Understanding the Difference: Therapeutic Exercise, Therapeutic Activity, and Neuromuscular Re-education in Occupational Therapy

Understanding the Difference between Therapeutic Exercise and Neuromuscular Re-Education in Occupational Therapy

As dedicated professionals in the field of occupational therapy, we are constantly striving to provide the best possible care for our clients. One crucial aspect of our practice is understanding the nuances between different treatment modalities and knowing when to apply each one effectively. It is important to know the distinctions between three commonly used billing codes: Therapeutic Exercise (97110), Therapeutic Activity (97530), and Neuromuscular Re-education (97112), with a focus on their relevance in adult populations.

Therapeutic Exercise (97110)

Therapeutic Exercise (97110): This billing code is utilized when engaging in interventions aimed at addressing specific joints, structures, or muscles. In alignment with the Biomechanical model of practice, therapeutic exercises are designed to remediate, restore, or maintain the integrity of these elements. Examples of treatments may include:

Strengthening exercises for individuals recovering from orthopedic surgeries such as total knee replacements.
Range of motion exercises for patients with rheumatoid arthritis to maintain joint mobility and prevent contractures.
Endurance training for individuals with chronic obstructive pulmonary disease (COPD) to improve tolerance for daily activities.

Neuromuscular Re-Education (97112)

Functional Ambulation Asymmetrical Stance and Gait

Neuromuscular Re-education (97112): Contrary to common belief, Neuromuscular Re-education (NMRE) does not exclusively pertain to neurological-based diagnoses. Instead, it encompasses various neurological models of practice within the occupational therapy scope. NMRE interventions target balance, coordination, kinesthetic sense, posture, and proprioception for sitting and/or standing activities. Examples may include:

Core stabilization exercises for individuals with low back pain to improve posture and prevent further injury.
Dual-tasking exercises for older adults at risk of falls to improve cognitive-motor integration and balance control.

Therapeutic Activities (97530)

Functional Ambulation-Carry, Modulation, Balance

Therapeutic Activity (97530): Therapeutic activities are movement-based interventions that occur outside of the personal context of the client but often simulate real-life tasks. These activities are designed to improve functional performance and are billed under the therapeutic activity code (97530). Examples include:

Simulated work tasks such as sorting objects or assembly tasks for individuals undergoing vocational rehabilitation.
Community mobility exercises such as navigating public transportation or crossing streets safely for clients with mobility impairments.
Environmental adaptations tasks such as practicing using adaptive equipment or modifying home environments for individuals with physical disabilities.

Core stabilization exercises for individuals with low back pain to improve posture and prevent further injury.
Dual-tasking exercises for older adults at risk of falls to improve cognitive-motor integration and balance control.

Bottom Line:

Understanding the distinctions between Therapeutic Exercise, Therapeutic Activity, and Neuromuscular Re-education is essential for providing comprehensive and effective care in occupational therapy practice. By selecting the appropriate billing code and tailoring interventions to the individual needs and goals of our clients, we can maximize outcomes and promote optimal function and participation in daily life.

Step, Tap, Align Group | Occupational Therapy Intervention

OT Practitioners

Group Therapy Intervention

Occupational Therapy Intervention : Group Therapy

Documentation and Activity Rationale

The patient engaged in a dual-tasking activity with an emphasis on visual memory and recall. The task required the patient to receive a 3-part image at point A, ambulate 20 ft while clearing obstacles of various sizes and heights, and recall and draw the image received at Pt A. This activity is purposed to improve the relationship between perceptual processing and encoding, storage, and retrieval of the resulting neural representations after approximately 10 seconds of time-lapse. The patient demonstrated no evidence of LOB or instability. She required between 2-3 repetitions per image with 2-3 verbal cues. 3 step directions are moderately difficult for the patient.

Grading Strategies

Grading Up:

more narrow BOS
increase the frequency of stepping
integrate dual-tasking (e.g. counting by 2’s)

Grading Down:

increase BOS
decrease stepping outside of BOS (e.g. “tap your foot to the side every 5 steps)

Appropriate Diagnoses / Deficits

Balance deficits
Memory Changes
CVA
TBI

One Leg Stance and Cross Midline Tap Group | Occupational Therapy Intervention

OT Practitioners

Group Therapy Intervention – Balance

Occupational Therapy Intervention : Group Therapy Intervention

Documentation and Activity Rationale

The patient engaged in LE dynamic balance activity designed to promote neuronal excitation, brain plasticity, interhemispheric communication, balance, agility, visualization, and stability. Alternating toe taps were completed invoking crossing midline using a visual target to ensure maximum range and visual perceptual skills, BUE cross midline, internal rotation, adduction > outside BOS. 15 reps were completed per LE.

Grading Strategies

Grading Up:

integrate dual-tasking
utilize directional component (e.g. “tap you left foot 3 times and your right foot 2 times)

Grading Down:

allow for one-handed support (e.g. a chair/non-wheeled walker)

Appropriate Diagnoses / Deficits

Balance deficits
Memory Changes
CVA
TBI

Wrist Flexion and Extension| Occupational Therapy Intervention

OT Practitioners

Wrist Flexion and Extention:

Forearm Strengthening

Occupational Therapy Intervention : Wrist Flexion and Extension

Documentation and Activity Rationale

The patient engaged in a wrist AROM against resistance provided by a 2lb weighted ball. The exercise sequence elicited wrist flexion and extension in order to increase extrinsic forearm musculature. The patient was instructed to perform each movement slowly, methodically, and with complete control. No pain or discomfort verbalized by the patient, though the patient affirmed muscle fatigue at the end of the sequence. Therapeutic rest given after task.

Grading Strategies

Grading Up:

include radial and ulnar deviation, circumduction, pronation and supination in the AROM sequence

Grading Down:

begin with less weight
fewer repetitions

Appropriate Diagnoses / Deficits

generalized weakness
atrophy s/p hand and/or wrist surgery
CVA
TBI

An occupational therapy practitioner would work on wrist flexion and extension using various shaped and weighted items, such as bars for cylindrical grasp, balls for spherical grasp, and books for specific grasp types, to achieve several therapeutic goals:

Strengthening Muscles: Different shapes and weights challenge the wrist flexor and extensor muscles, promoting muscle strengthening and endurance. This is crucial for improving overall wrist stability and function.

Enhancing Grip Variety: Practicing with various objects helps to enhance different types of grips such as cylindrical, spherical, and pinch grasps. This diversity in training ensures that patients can perform a wide range of everyday activities.

Improving Dexterity and Coordination: Using objects of different shapes and sizes requires fine motor skills and coordination. This helps to improve hand-eye coordination and dexterity, which are essential for precise movements.

Functional Application: Activities that involve gripping and manipulating different objects are directly related to daily tasks such as opening jars, picking up objects, and using tools. Training with these objects simulates real-life scenarios, making the therapy functional and relevant to the patient’s daily life.

Promoting Motor Control: Varying the resistance and shape of objects helps in refining motor control and proprioception, which are important for smooth and controlled movements of the wrist and hand.

Addressing Specific Deficits: Different objects target specific muscle groups and movement patterns. For example, using cylindrical objects primarily targets wrist flexion and extension, while spherical objects challenge the intrinsic muscles of the hand.

Encouraging Neural Adaptation: Engaging in diverse and challenging tasks promotes neuroplasticity, which is the brain’s ability to reorganize itself by forming new neural connections. This is especially important for patients recovering from neurological injuries.

Here’s an example of how specific objects can be used:

Cylindrical Grasp: Bars or tubes to improve wrist flexion and extension strength.

Spherical Grasp: Balls to enhance overall grip strength and coordination.

Lateral Pinch: Books or flat objects to practice the lateral pinch grasp, improving precision grip used in activities like holding cards or sheets of paper.

Baoding Balls | Occupational Therapy Interventions

OT Practitioners

Fine Motor Strengthening – Baoding Balls

Occupational Therapy Intervention : Fine Motor Strengthening

Documentation and Activity Rationale

The patient engaged in Baoding balls 2 x 2-minute intervals in the left hand to promote intrinsic muscle strength, stability, and control and wrist, muscle isolation, manipulation, passive tendon glides, and muscle stamina/endurance.

Grading Strategies

Grading Up:

the ultimate goal is to have enough control in order for the balls not to touch

Grading Down:

decrease time and repetitions

Appropriate Diagnoses / Deficits

generalized weakness
atrophy s/p hand and/or wrist surgery
CVA
TBI

Baoding balls, also known as Chinese meditation balls, are small, handheld balls that can be rotated in the palm. Traditionally used for relaxation and stress relief, Baoding balls have found a valuable place in occupational therapy for their ability to enhance fine motor skills, dexterity, and hand strength. They are versatile tools that can be adapted for use with a variety of clients, from children to older adults, and for a range of therapeutic goals.

Benefits and Applications of Baoding Balls

In-Hand Manipulation

Finger Isolation and Coordination: Rotating Baoding balls requires precise movement of the fingers, promoting finger isolation and coordination. This skill is essential for tasks like typing, writing, and using utensils.
Dexterity: The challenge of moving the balls in different directions and patterns enhances dexterity. This improves the ability to perform complex hand movements required in activities like playing musical instruments or engaging in crafts.

Intrinsic and Extrinsic Hand Strengthening

Intrinsic Muscles: These small muscles within the hand are crucial for fine motor control. Using Baoding balls can help strengthen these muscles, improving grip strength and the ability to perform delicate tasks.
Extrinsic Muscles: The larger muscles that control the hand movements from the forearm also benefit from this exercise. Stronger extrinsic muscles support activities that require sustained hand and wrist movements, such as gardening or lifting objects.

Calming and Attention

Mindfulness and Stress Relief: The rhythmic, repetitive motion of Baoding balls can have a calming effect, similar to meditation. This helps reduce stress and anxiety, promoting a sense of well-being.
Improved Focus: Engaging in the activity requires attention to the movements, which can help improve focus and concentration. This can be particularly beneficial for individuals with ADHD or other attention-related challenges.

From Therapy to Everyday Life: The Occupational Benefits of Baoding Balls

Baoding balls are more than just therapeutic tools; they serve as bridges to enhanced occupational performance. By incorporating Baoding balls into therapy sessions, clients can experience significant improvements in their daily activities. For example, the improved in-hand manipulation and finger coordination developed through the use of Baoding balls can directly enhance handwriting and typing skills. This is crucial for students, professionals, and anyone who needs to communicate effectively through written words. The strengthened intrinsic and extrinsic hand muscles gained from Baoding ball exercises translate to greater ease in performing everyday tasks such as buttoning clothes, opening jars, or carrying grocery bags. These improvements lead to increased independence and confidence in daily life.

Moreover, enhanced dexterity and fine motor control benefit clients in their hobbies and recreational activities, such as playing musical instruments, painting, or engaging in crafts, ultimately enhancing their quality of life and personal satisfaction. The calming effect and improved focus resulting from the rhythmic, repetitive motion of Baoding balls help clients manage stress and maintain attention during work or study, which is particularly beneficial in high-stress occupations or academic settings. Additionally, the integration of cognitive and motor skills developed through Baoding ball exercises supports better performance in tasks that require both cognitive and motor abilities, such as cooking (following a recipe while handling utensils) or driving (processing information while controlling the vehicle). Overall, the use of Baoding balls in therapy promotes safer and more effective task performance, helping clients achieve greater independence and an improved quality of life.

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In Hand Coin Manipulation | Occupational Therapy Intervention

OT Practitioners

In-Hand Coin Manipulation

Occupational Therapy Intervention : Fine Motor Coordination using Coin Manipulation

Documentation and Activity Rationale

The patient engaged in a fine motor coin manipulation activity using right hand (left hand to assist prn) to retrieve coin using thumb abduction and/or tip pinch, maintain grip and place into a slightly resistive target. The patient was very challenged by this activity requiring frequent adaptations. Patient was unable to retrieve independently requiring max ax1/and placement of coin in webspace of thumb x10 coins. The activity seeks to elicit fine motor active range of motion, coordination, pinch strength, translation, and skills of prehension.

Grading Strategies

Grading Up:

smaller coins
more coins

Grading Down:

larger opening to release into
less coins at one time

Appropriate Diagnoses / Deficits

coordination deficits
atrophy s/p hand and/or wrist surgery
CVA
TBI

In-hand coin manipulation using actual coins in occupational therapy treatments helps to ensure the therapy is task-specific, engaging, and objective. Here’s how:

Task-Specific

Functional Relevance: Manipulating coins is a common daily activity, making it highly relevant and practical for patients. This ensures that the skills practiced in therapy can be directly transferred to real-life situations.
Fine Motor Skills: Coin manipulation specifically targets fine motor skills, including dexterity, finger strength, and coordination, which are crucial for many everyday tasks such as buttoning clothes, writing, or handling small objects.

Engaging

Motivating Activity: Using real coins can be more interesting and engaging for patients compared to abstract exercises. The familiarity and tangible nature of coins can make the activity feel more purposeful and motivating.
Variety and Challenge: Coins of different sizes and weights provide varied challenges, keeping the activity interesting and progressively difficult as the patient’s skills improve.

Objective

Measurable Progress: Coin manipulation tasks can be easily quantified, allowing therapists to objectively measure progress. For example, the number of coins manipulated within a set time frame or the ability to perform specific coin tricks can be tracked and recorded.
Standardized Tasks: Using coins allows for standardized tasks, such as picking up coins from a flat surface, sorting them, or moving them from palm to fingertips. This standardization helps in objectively assessing and comparing patient performance over time.

Specific Therapeutic Benefits

Strengthening Intrinsic Hand Muscles: Manipulating coins strengthens the small muscles in the hand and fingers, crucial for grip and precision tasks.
Enhancing Coordination: The activity requires coordination between fingers, improving fine motor control and hand-eye coordination.
Improving Sensory Feedback: Handling coins provides tactile feedback, enhancing sensory perception and proprioception in the hands.
Promoting Cognitive Skills: Sorting and counting coins can also engage cognitive functions such as attention, sequencing, and problem-solving.

Practical Application

Grading the Activity: The complexity of the task can be easily adjusted by changing the size, weight, and number of coins, or by varying the speed and accuracy requirements.
Engaging Multiple Systems: Coin manipulation tasks can integrate sensory, motor, and cognitive systems, providing a comprehensive approach to rehabilitation.

In-hand coin manipulation, therefore, offers a practical, engaging, and measurable way to improve fine motor skills and hand function in occupational therapy.