CHAPTER

8   Hand Function Evaluation and Intervention

Jane Case-Smith  •  Charlotte E. Exner

mechanisms, cognition, social-emotional function, and visual

KEY TERMS perception. The term visual-motor integration refers to the
interaction of visual skills, visual-perceptual skills, and motor
Hand function Neurodevelopmental
skills. The term hand function is used interchangeably with the
Reach and carry therapy
Grasping patterns Motor learning terms fine motor coordination, fine motor skills, and hand skills,
In-hand manipulation Constraint induced and this chapter uses the term hand function to refer to all of
Bimanual skills movement therapy these skills.
Biomechanical Adaptation and assistive Although a child’s development of hand functions depends
approaches technology on adequate postural functions and sufficient visual-perceptual
and cognitive development, these areas are described in other
chapters and not in detail in this chapter. Patterns of hand
GUIDING QUESTIONS function include reach, grasp, carry, and voluntary release, as
well as the more complex skills of in-hand manipulation and
1. What is the sequence of hand function development bimanual skills. These terms are briefly defined:
in infants and children? • Reach: extension away from the body and movement of the
2. Which factors contribute to development of hand arm for grasping or placing objects
function? • Grasp: attainment of an object with the hand; holding
3. How do hand function problems affect children’s within the hand
occupational performance? • Carry: transportation of a hand-held object from one place
4. Which assessment tools and methods are useful in to another
evaluating children’s hand skills? • Voluntary release: finger extension allowing intentional
5. How are intervention practice models and principles release of a hand-held object at a specific time and place
used by occupational therapists to promote hand • In-hand manipulation: adjustment or movement of an
function? object within the hand
6. Given a range of diagnoses, how do occupational • Bimanual skills: coordinated use of two hands together
therapists use specific intervention strategies to sequentially or simultaneously to accomplish an activity
improve hand function?
7. How do assistive technologies and adapted
techniques improve children’s hand function and
increase participation in play, school, and activities of Factors That Contribute to the
daily living? Development of Hand Function
8. How does research support occupational therapy
practice models for hand function interventions? Occupational therapists often use occupation-based models
Copyright © 2014. Elsevier. All rights reserved.

and dynamic systems theory to understand development of

Hand function is critical to children and youth’s interaction inter-related performance areas. Through the lens of these con-
with objects (e.g., tools), materials, and other persons within ceptual models, a child’s performance reflects his or her innate
everyday environments. Hands are the dynamic “tools” most developmental abilities and the contextual opportunities and
often used to accomplish activities of daily living (ADLs), barriers that affect performance. As described in Chapters 2 and
school, work, and play activities. The child who has a disability 8, performance is dynamically influenced by intrinsic variables,
affecting hand function has less opportunity to interact with, including motivation, cognition, and social-emotional function
explore, and act on the environment. as well as extrinsic variables, including the social, physical, and
cultural context. These models are used to guide analysis of
hand function by identifying potential factors associated with
Components of Hand Skills a child’s delay or impairment in hand function. Using a top-
down approach, this section describes factors that influence
Effective use of the hands to engage in a variety of occupations the development of hand function, recognizing that as a
depends on a complex interaction of hand functions, postural child develops, the factors associated with efficient hand use

220
Case-Smith, J., & O'Brien, J. C. (2014). Occupational therapy for children and adolescents. Retrieved from http://ebookcentral.proquest.com
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 CHAPTER  8  Hand Function Evaluation and Intervention 221

and skilled manipulation of objects have greater or lesser proficient hand skills at early ages may relate to using chop
influence. sticks to eat, having less access to gross motor activities, or
attending early childhood programs that emphasize writing.
Although dexterity of children in Eastern cultures may be
Social and Cultural Factors higher than that of American children, hand strength may be
Knowledge of contextual factors is critical for understanding, lower. Studies have found that on average, children from
evaluating, and providing interventions to enhance hand func- Eastern cultures, such as Korea, demonstrate lower hand
tions. Social and cultural factors, in particular, are likely to play strength than children of Western cultures.131
important roles in the acquisition and use of various hand skills. Although contextual variables influence a child’s develop-
Social factors that can affect the development of hand functions ment of hand function, intrinsic variables, including the child’s
include socioeconomic status, gender, and role expectations. somatosensory functions, visual perception, and cognition,
These cultural and social factors may not influence the develop- have strong, direct association with the child’s rate of develop-
ment of basic hand skills but can influence the development of ment, level of performance, and proficiency across tasks.
complex manipulation of objects and tool use. For example, Musculoskeletal integrity also influences patterns of hand
children who live in conditions of poverty may not have access function, coordination, and dexterity. As hand functions
to writing utensils, scissors, and other materials common to mature beyond grasp and release patterns, children learn to
children from middle-class environments. coordinate visual skills with hand skills, develop praxis and
The objects that are important to the child’s cultural group dexterity, and later, coordinate visual-perceptual and motor
influence the development of object manipulation. Because planning skills.37,98
tools that are important in one culture may not be available in
another, children may not have the opportunity to develop
some tool-specific skills. For example, eating utensils vary from Somatosensory Functions
chopsticks to forks and spoons. Scissors use may be important The role of somatosensory information and feedback is critical
for school performance in some cultures but not in others. As in the development of hand functions, particularly those involv-
explained by Flynn and Whiten,53 children’s pattern of tool use ing isolated movements of the fingers and thumb. Practitioners
is influenced by observing the actions of familiar individuals acknowledge that intact somatosensory functioning is required
using tools over time, thereby reinforcing the significance of for development of precise and dexterous hand and finger
that action to the child. Children learn to use tools through movements. Haptic perception is the child’s interpretation
repeated observation of adults and their peers, suggesting of somatosensory information (through active touch) for pur-
that tool use may be delayed when models are not available poses of understanding object properties and characteristics.
and most often reflect patterns within their immediate Although haptic perception emerges by 6 months when grasp-
environments. ing patterns are immature, full haptic perception (perception
In addition, the age at which children are expected to of object texture, shape, and hardness through active touch)
achieve skills in object manipulation can vary. Safety concerns does not mature until 5 or 6 years when the child can manipu-
influence parents in some cultural groups to delay introduction late objects within the hand.13 As a more direct sense than
of a knife to a child, whereas parents in other cultural groups vision, haptic perception allows for immediate feedback on
encourage early independence in knife use.109 Some cultures the child’s use of force, accuracy of movement, and precision
introduce children to the use of writing materials before 1 year of movement.111 A 6-year-old can identify three-dimensional
of age. Parents from other cultures and socioeconomic groups common objects and all aspects of objects’ characteristics by
do not provide children with these materials until they can be active touch alone.21
expected to adhere to requirements such as using them only The fingertips gather precise information about many types
on paper (rather than on the wall or on clothing). of object qualities. Children with impaired control of finger
Culture also influences the perception of children’s need movement have limited access to somatosensory information,
for manipulative materials and the cultural group’s view of and/or the impaired control of finger movement may reflect
the importance of play. Play materials that provide opportuni- their difficulties in perceiving and using sensory information.
ties for the development of manipulative skills (e.g., building Initiating and sustaining grasp force requires tactile and pro-
sets, beads, puzzles, table games) are highly valued in some prioceptive input and integration, and the ability to hold
Copyright © 2014. Elsevier. All rights reserved.

cultural groups, whereas in other groups, play with gross motor objects in the hand (i.e., without dropping them) is related
objects (e.g., balls, riding toys) or play with animals is primarily to intact somatosensory functioning.55,58,59 Hand
more valued. Some cultural groups do not view children’s functions and accurate use of force clearly relate to tactile sen-
play as important; therefore few play materials of any type are sibility; for example, in children with cerebral palsy, tactile
available.6 information was found to be critical for anticipating the amount
Although the types of activities encouraged can promote the of force needed to grasp and lift an object.56
development of specific skills, acquisition of the basic hand Somatosensory functioning is difficult to assess in children,
functions of reach, grasp, release, and manipulation does not particularly in young children (e.g., less than 4 years) and
rely on the availability of any particular materials; rather, it relies those with disabilities. When testing haptic perception (e.g.,
on reasonable exposure to a variety of materials with the oppor- using stereognosis) or tactile sensitivity (e.g., using two-point
tunity to handle them. In a comparative study of children in discrimination), a child’s performance often varies within
Hong Kong and those in the United States, children in Hong a session or from one session to another. Although formal
Kong demonstrated higher level manual dexterity and, at testing may be unreliable, therapists informally evaluate somato-
earlier ages, more proficient writing.23 Hong Kong children’s sensory functioning to understand delays or impairment in

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 222 SECTION  III Occupational Therapy Intervention: Performance Areas

hand function. For example, a child with poor somatosensory months, he or she bangs two objects together and, at 15
registration may engage in few activities involving active manip- months, he or she stabilizes an object with one hand while
ulation. A child with tactile hypersensitivity may avoid contact manipulating with the other. With further cognitive develop-
with certain materials, thus limiting exposure to various objects. ment, the toddler, at 18 to 20 months, manipulates two or
Limitations in somatosensory function are associated with poor more objects simultaneously. As attention and planning skills
coordination, problems in timing and speed of response, and increase, the child develops facility in using two hands together
clumsiness, including dropping objects or use of excessive to manipulate objects.17,27
force.57 In particular, children with cerebral palsy35,56 and devel-
opmental coordination disorder (DCD)78 often demonstrate
these somatosensory perception difficulties and associated Musculoskeletal Integrity
impaired hand function. The integrity of the hand’s joint and bone structures is an
important consideration in hand function. Children with con-
genital hand anomalies may be missing one or more digits, a
Visual Perception and Cognition condition that significantly affects the variety of possible pre-
Visual perceptual and visual-motor development has a major hension patterns. Refined finger movements and in-hand
role in the development of hand function.9,21,71 Vision is par- manipulation skills may also be limited or absent. Congenital
ticularly important for learning new motor skills. The 4-month- anomalies in which the thumb is missing or contracted signifi-
old infant uses vision as a dominant sense to guide arm and cantly affect grasp. Children with congenital anomalies affect-
hand movements in reaching for objects and making differenti- ing hand structures often undergo orthopedic surgeries to
ated finger movements. The visual-motor development required optimize grasp and hand function.
for accurate reach matures by approximately 6 months of age. Limitations in joint range of motion (ROM) can occur as a
During the first 6 months, the infant demonstrates emerging result of abnormal joint structure, muscle weakness, abnormal
skills in using visual and tactile perception to guide reach, muscle tone, or joint inflammation. These limitations can affect
object carry, and object placement.110 The infant’s visual-motor the child’s range of reach and carry, active supination for tool
coordination continues to refine, and by 9 months of age uses, and hand and finger mobility. Effective hand function
the infant guides his or her hand movements using visual- depends on adequate mobilization of distal muscle groups that
somatosensory integration (i.e., these sensory inputs are com- control palmar arches. ROM limitations or hand contractures
bined and compared as the infant anticipates and plans arm and affect a child’s ability to grasp small or large objects, use
hand movements). dynamic grasp and release patterns, and move objects within
Because the child acquires knowledge about objects through the hand.
object manipulation, hand use and cognitive development Aspects of muscle functions include muscle power (strength),
seem to be particularly linked in infancy and very early child- muscle tone, and muscle endurance. Sufficient strength is nec-
hood.50 Early manual exploratory behavior plays an important essary to initiate all types of grasp patterns and to maintain
role in the development of visual-spatial skills and learning these patterns during lifting and carrying. Children’s grasp
about the environment.96,112 Object manipulation in infants strength gradually increases through the preschool years,80 the
between 6 and 12 months of age leads to learning about object elementary school years,131 and adolescence.25 This increase
characteristics and understanding of spatial relationships. For allows them to engage in activities with objects of increasing
example, by 9 to 10 months of age, infants adapt their arm weight and to use greater resistance.
positions to horizontal versus vertical object presentations Children with poor strength may be unable to initiate the
and shape their hands appropriately for convex and concave finger extension or the thumb opposition pattern necessary
objects.110 before grasp. They also may not have the flexor control to hold
During the second year, infants learn to relate objects to a grasp pattern. Many children with diminished strength are
one another with more accuracy and purpose. Before 18 unable to use patterns that rely on the intrinsic muscles for
months of age, infants modify their movement approach in control and therefore are unable to use thumb opposition or
anticipation of the weight of the object.13,27 As eye-hand coor- metacarpophalangeal (MCP) joint flexion with interphalangeal
dination continues to develop, the toddler learns movements (IP) joint extension. Children with fair strength may be able
that require precise guidance by vision (e.g., stringing small to initiate a grasp pattern but may be unable to lift an object
Copyright © 2014. Elsevier. All rights reserved.

beads or putting together a puzzle). For example, in the second against gravity while maintaining the grasp. Children with
half of the first year the infant adjusts the actions of the hand mildly diminished strength may demonstrate limited activity
in response to object characteristics, such as size, shape, and endurance, particularly in situations in which they must use a
surface qualities.27 By preschool age, the development of hand sustained grasp pattern or hold an object against resistance
function allows for more complex interaction with objects, and (e.g., during eating with utensils, coloring, handwriting, and
the child uses well-developed visual-perceptual skills to guide scissors activities).
manipulation of objects in the course of play and social When children with cerebral palsy demonstrate increased or
interaction. decreased muscle tone in the upper extremity, arm and hand
Like visual-perceptual skills, cognitive skills are associated movements tend to be unstable and motor control is dimin-
with the development of hand function in the young child.82 ished. Finger and hand movements are often limited or missing.
Changes in attentional control and the development of Children with spasticity or hypertonicity frequently demon-
problem-solving strategies are seen in the infants’ gradual strate limited ROM, poor control, and decreased movement
improvement in handling two objects simultaneously. The efficiency. Children with hypotonia or low muscle tone often
infant attends to two objects simultaneously when, at 10 exhibit exaggerated joint ROM and decreased stability. With

Case-Smith, J., & O'Brien, J. C. (2014). Occupational therapy for children and adolescents. Retrieved from http://ebookcentral.proquest.com
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 CHAPTER  8  Hand Function Evaluation and Intervention 223

fluctuating tone, a child may have full ROM but attains joint hands further away to view them. This pattern precedes the
stability only at the extreme end of a joint position (full flexion onset of symmetric bilateral reaching, which usually occurs
or full extension). With fluctuating tone, movements are first in the supine and then in the sitting position. At this
less controlled and appear to be random or unrelated to the stage the infant initiates reach with humeral abduction, partial
child’s goal. shoulder internal rotation, forearm pronation, and full finger
Although intrinsic and extrinsic factors influence the devel- extension.110
opment of hand function, the sequence of hand skill develop- As the infant shows increasing dissociation of the two body
ment is remarkably similar in typical children. The sequence of sides during movement, unilateral reaching begins. Abduction
development guides the occupational therapist in evaluating and internal rotation of the shoulder are less prominent in
hand function and fine motor skills, establishing goals that reach. The hand opens in preparation for grasping the object
reflect the next developmental steps, and selecting develop- and is usually more open than necessary for the size of the
mentally appropriate activities as the context for intervention. object.128
As scapular control and trunk stability mature, the infant
begins to use shoulder flexion, slight external rotation, full
Development of Hand Skills elbow extension, forearm supination, and slight wrist extension
during reaching. Active supination of the forearm requires
Developmental theories and principles are used in conjunction some external rotation of the shoulder to stabilize the humerus.
with other practice models to select appropriate goals, design In addition, well-controlled elbow extension evolves as control
intervention activities, and assess the child’s progress. The of shoulder rotation develops. Mature reach is usually seen with
occupational therapist uses comprehensive knowledge of hand sustained trunk extension and a slight rotation of the trunk
function development to select tasks that challenge the child’s toward the object of interest. Over the next few years the child
emerging skills and provide or fade out supports that enable refines this unilateral reaching pattern, increasing the accuracy
the child to reach the next developmental level. Hand functions of arm placement and the grading of finger extension as appro-
develop through childhood, continuing into the adolescent priate to the size of the object (Figure 8-1), as well as the
years.4,46 This long course of development mirrors other aspects timing of the various movement elements. With increasing age,
of development and reflects the complexity of hand skills as reaching patterns become direct, highly accurate, and highly
humans interact with objects and their environments. Devel- consistent. The quality of reach with grasp continues to mature
opmental theories are further described in Chapter 3; this until approximately 12 years of age, at which time the child
section describes the sequence of hand function development prepares the hand with the optimal hand opening for the object
by considering its components. size at the initiation of reach.75
Carrying (moving and lifting) involves a smooth combina-
tion of body movements accompanied by stabilization of an
Reach and Carry object in the hand. When carrying objects to perform a task,
An important sequence in the development of motor control small ranges of movements are used and adjusted in accordance
is the use of linear movement patterns before the emergence with the demands of the activity. The child carries an object by
of controlled rotation patterns. As illustrated in the develop- maintaining co-contraction of the forearm, wrist, and hand and
ment of reach and carry, the infant first develops controlled may modify the forearm and wrist positions to correctly orient
stability and mobility in basic flexion and extension of the the object. Similarly, the child uses shoulder rotation move-
shoulder, elbow, and wrist. Within the first year, control of ments with shoulder flexion and abduction to orient the object
internal and external rotation of the shoulder and pronation during carry.
and supination of the forearm emerges and these rotational arm
movements characterize the reaching patterns required in func-
tional tasks (e.g., reach to be picked up, reach for a bottle or
cup). The goal of reach is to transport the hand to the target,
with precision in both time and space,110,117 and therefore
requires control of the hand’s movement toward the object and
the preparation of the hand for grasp.
Copyright © 2014. Elsevier. All rights reserved.

Within the first several days of life the neonate shows visual
regard of objects close to him or her and activation of the arms
in response to objects.126 Over the next few months of life the
arms become more active and the infant swipes or bats at
objects with the arm abducted at the shoulder. Reach with an
extended arm to contact an object with the hand is likely to
occur between approximately 12 and 22 weeks of age.126,127
Objects are rarely grasped and then only by accident. If grasped,
they are released at random, generally in association with arm
movements.
By 3 to 4 months a midline orientation of the hands devel-
ops. Initially the hands are held close to the body. Soon, with
an increased desire for visual regard of the hands and greater FIGURE 8-1  A 2-year-old shows refinement of unilateral
proximal arm stability, the 4- to 5-month-old infant holds the reach with graded finger extension.

Case-Smith, J., & O'Brien, J. C. (2014). Occupational therapy for children and adolescents. Retrieved from http://ebookcentral.proquest.com
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 224 SECTION  III Occupational Therapy Intervention: Performance Areas

explore them and relate them to other objects interact with

Grasp Patterns motor and sensory development to influence the grasp patterns.
Broadly, grasp patterns are determined by whether a person Haptic development and visual-perceptual development con-
needs to perform with precision or power to accomplish an tribute to the infant’s ability to shape the hand to the object’s
activity. Precision grasps involve opposition of the thumb to form and to approach the object with optimal orientation of
fingertips. Power grasps involve the use of the entire hand. In the arm and hand.
a power grasp, the thumb is held flexed or abducted to other Another aspect of motor development that contributes to
fingers, depending on control requirements. In most cases the the infant’s use of increasingly mature and more varied patterns
activity and the object’s characteristics determine the grasp is the arm’s internal stability to hold a position of forearm
pattern used. Small objects are generally held in a precision supination and wrist extension. Stability of wrist and forearm
grasp, using the extensive sensory feedback available through allow controlled thumb opposition and isolated finger move-
the fingertips and the fine control of intrinsic muscles. Medium ments for precision grasp patterns. The ability to stabilize the
objects can be held with either pattern, and large objects are wrist in a slightly extended position is important for grasp pat-
generally held with a power grasp. The child uses interplay terns that use distal (fingertip) control. Slight forearm supina-
between precision and power handling of objects based on the tion positions the hand so that the thumb and radial fingers
activity demands.17,98 Specific grasp patterns are described in are free for active object exploration and allows the infant to
Table 8-1. view fingers and thumb during grasp.17
The typical sequence of grasp development begins with the
Sequential Development of Grasp Patterns neonate appearing to have no voluntary hand use. A newborn
The sequences of grasp pattern development reflect three infant’s hands alternately open and close in response to sensory
types of progression: (1) Ulnar fingers show activation before input. Within the first 3 months the automatic traction response
radial fingers and thumb; (2) palmar grasp (proximal) patterns and grasp reflex decrease, and a voluntary palmar grasp emerges
precede finger grasp (distal) patterns; and (3) extrinsic muscle (Figure 8-2). By approximately 6 months the infant exhibits a
activation dominates before intrinsic muscle activation. These radial palmar grasp when prehending objects.
progressions interact and overlap as the infant develops. The The second 6 months is a significant period for the develop-
infant’s growing interest in objects and desire to attain and ment of hand skills. The ability to grasp a variety of objects

TABLE 8-1 Mature Grasping Patterns Used in Functional Activities

Grasp Pattern Functionality Description

Power grasp Used to control tools or other The object is held obliquely in the hand; ulnar fingers are flexed; radial
objects. Used with hand fingers are less flexed. Thumb is in extension and adduction. The child
strength is required in stabilizes the object with the ulnar side of the hand and controls the
activity object using the radial side of the hand.
Hook grasp Used to carry objects such as The transverse metacarpal arch is flat; the fingers are adducted with flexion
a purse or briefcase at the interphalangeal (IP) joints. The metacarpophalangeal (MCP) joints
may be flexed or extended.
Spherical grasp Used to hold a small ball The wrist is extended, fingers abducted, with some flexion at the MCP and
IP joints. Stability of the longitudinal arch is needed to use this pattern
to grasp a larger ball. The hypothenar eminence assists in cupping the
hand for control of the object.
Cylindrical grasp Used to hold a glass, cup, or The transverse arch is flattened to allow the fingers to hold against the
can with hand around the object. The fingers are only slightly abducted, and IP and MCP joint flexion
object is graded according to the size of the object. When additional force is
required, more of the palmar surface of the hand contacts the object.
Disk grasp Used to hold a disk such as a The fingers hold the disk with extension of the MCP joints and flexion of
Copyright © 2014. Elsevier. All rights reserved.

jar lid the IP joints. The wrist flexes and thumb extends when objects are larger,
and only the pads of the fingers contact the object. This pattern involves
dissociation of flexion and extension movements and use of a
combination of wrist flexion with MCP extension and IP flexion.
Lateral pinch Used to exert power on or The index finger is slightly flexed and the thumb is flexed and adducted.
with a small object The pad of the thumb is placed against the radial side of the index
finger at or near the distal interphalangeal (DIP) joint.
Pincer grasp Used to hold and handle The thumb is opposed to the index finger pad and the object is held within
small objects and precision the finger pads. The ulnar fingers are often flexed.
tools (e.g., a pencil)
Three-jaw chuck Used to hold and manipulate The thumb is simultaneously opposed to the index and middle finger pads.
or tripod a writing utensil or eating These fingers provide stability for prehension of a tool. The thumb forms
grasp utensil an oval or a modified oval shape with the fingers. When using a tripod
grasp on a tool, the forearm is slightly supinated.
Tip pinch Used to prehend and hold The thumb is opposed with thumb tip meeting index finger tip, forming a
tiny objects circle. All joints of the index finger and thumb are partly flexed.

Case-Smith, J., & O'Brien, J. C. (2014). Occupational therapy for children and adolescents. Retrieved from http://ebookcentral.proquest.com
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 CHAPTER  8  Hand Function Evaluation and Intervention 225

FIGURE 8-2  A 4-month-old exhibits voluntary palmer FIGURE 8-3  This child uses a radial-digital grasp to hold a
grasp.  (From Case-Smith, J. (2013). Applying occupation rattle.  (From Case-Smith, J. (2013). Applying occupation
and motor learning principles in pediatric CIMT: Theoretical and motor learning principles in pediatric CIMT: Theoretical
foundations and conceptual framework. In S. L. Ramey, P. foundations and conceptual framework. In S. L. Ramey, P.
Coker-Bold, & S. C. DeLuca (Eds.). Handbook of pediatric Coker-Bold, & S. C. DeLuca (Eds.), Handbook of pediatric
constraint-induced movement therapy (CIMT) (pp. 41–54). constraint-induced movement therapy (CIMT) (pp. 41–54).
Bethesda, MD: AOTA Press.) Bethesda, MD: AOTA Press.)

increases significantly between 6 and 9 months of age. During grip, key (lateral) pinch, and tripod (three-point) pinch signifi-
this time grasp patterns with active thumb use emerge. Crude cantly increase in children between 3 and 5 years of age.81
raking of a tiny object is present by about 7 months of age, Strength appears to continue to increase in grip, lateral pinch,
and by 9 months of age the infant holds a tiny object between palmar pinch, and tip pinch until children reach 12 years, with
the finger surface and the thumb. By 8 to 9 months of age the differences in grip strength between boys and girls common.86
infant grasps a larger object between the thumb and the radial Isometric force gradually increases during the 5- to 10-year-old
fingers (Figure 8-3) and readily varies the grasping pattern age span, reflecting corticospinal system maturation.119,120
according to the shape of the object. However, intrinsic muscle Compared with 10- to 12-year-olds, adults exhibit greater iso-
control is not yet effective because the infant does not use grasp metric strength and use alternative strategies for selecting and
with MCP flexion and IP extension. Between 9 and 12 months monitoring the hand strength needed during a task.51
of age, refinement occurs in the ability to use thumb and finger
pad control for tiny and small objects. More precise preparation
of the fingers before initiation of grasp, more inhibition of the In-Hand Manipulation Skills
ulnar fingers, and slight wrist extension and forearm supination In-hand manipulation includes five basic types of patterns:
are characteristics of this refinement. finger-to-palm translation, palm-to-finger translation, shift,
After 1 year of age the infant further refines grasp patterns simple rotation, and complex rotation.44 All skills require the
Copyright © 2014. Elsevier. All rights reserved.

and more sophisticated patterns emerge. By 15 months the ability to control the arches of the palm (Figure 8-4, A and B).
infant can hold crackers, cookies, and other flat objects, signify- In finger-to-palm translation, the child grasps the object with
ing increasing control of the intrinsic muscles. Between 18 the pads of the fingers and thumb and moves it into the palm.44
months and 3 years of age most children with typical develop- The finger pad grasp is released so that the object rests in the
ment acquire the ability to use a disk grasp, a cylindrical grasp, palm of the open hand or is held in a palmar grasp. The child
and a spherical grasp with control (see Table 8-1). Control of moves the object in a linear direction within the hand, and the
a power grasp continues to develop through the preschool fingers move from an extended to flexed position during the
years. The pattern for a lateral pinch may be present by 3 years translation. An example of this skill is picking up a coin with
of age, but children generally do not use this pattern with power the fingers and thumb and moving it into the palm of the hand.
until later in the preschool years. Overall grasp patterns for a Palm-to-finger translation is the reverse of finger-to-palm
variety of objects are well developed by 5 years of age, but those translation and requires isolated control of the thumb.43,99 In
involving tools may continue to mature into the early school palm-to-finger translation, the child begins with finger flexion
years.88,98 and moves to finger extension (see Figure 8-4, B). This pattern
In addition to refinement of grasp patterns, strength of is more difficult for the child to execute than finger-to-palm
grasp increases throughout childhood. Strength for palmar translation. An example of this skill is moving a coin from the
Case-Smith, J., & O'Brien, J. C. (2014). Occupational therapy for children and adolescents. Retrieved from http://ebookcentral.proquest.com
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 226 SECTION  III Occupational Therapy Intervention: Performance Areas

The two patterns of rotation are simple rotation and complex

rotation. In simple rotation the child turns or rolls an object
held at the finger pads approximately 90 degrees or less.44 The
fingers act as a unit, without differentiation of action, and the
thumb is in an opposed position. Examples of simple rotation
are unscrewing a small bottle cap, reorienting a puzzle piece in
the hand by turning it slightly before placing it in the puzzle,
and picking up a small peg and rotating it from a horizontal to
a vertical position for insertion into a pegboard.
In complex rotation, the child rotates a small object 180 to
360 degrees once or repetitively.44,100 During complex rotation
the fingers and thumb alternate in producing the movement,
and the fingers typically move independently of one another.
An object may be moved end over end, such as in turning a
coin or a peg over or in turning a pencil over to use the eraser.
A In-hand manipulation skills also are used when a child has
two or more pieces of cereal in his or her hand and moves one
piece to the finger pads before placing it in the mouth. The
term with stabilization refers to the use of an in-hand manipula-
tion skill while other objects are stabilized in the hand. In-hand
manipulation skills with stabilization are generally more diffi-
cult to perform than the same skill without the simultaneous
stabilization of other objects in the hand.

Developmental Considerations
Postural and motor skill prerequisites for in-hand manipu-
lation and dynamic grasping patterns include that the child
demonstrates:
• Active forearm supination with stability when moving hand
and fingers
• Wrist extension with stability
• Controlled and dynamic thumb opposition
• Fingertip prehension of objects with control of fingertip
forces
• Isolated thumb and radial finger movement
• Stability with mobility of the transverse MCP arch
• Dissociation of the radial and ulnar sides of the hand44
Children with delayed or limited in-hand manipulation
B
skills are likely to substitute other patterns. Typical patterns
FIGURE 8-4  A, In emerging in-hand manipulation skills, that compensate for limited in-hand manipulation include (1)
child demonstrates increasing control of isolated finger changing hands, (2) transferring from hand to hand, or (3)
movements. B, In buttoning, child uses palm-to-finger stabilizing the object on a table surface to reorient its position.
translation. The child uses these patterns after the initial grasp when he or
she realizes that the object needs to be repositioned for use. For
example, a child picks up a crayon with the right hand but is
palm of the hand to the finger pads before placing the coin in unable to shift it to place the fingers near the writing end; there-
a vending machine. fore, he or she grasps the object with the left hand and then
Copyright © 2014. Elsevier. All rights reserved.

Shift involves linear movement of the object on the finger transfers it back to the right hand. Some children preplan for
surface to allow for repositioning of the object on the pads of this by picking up the crayon with the non-preferred hand and
the fingers.44,98 In this pattern the fingers move just slightly at changing it to the preferred hand. Children commonly use two
the MCP and IP joints, and the thumb typically remains hands to compensate for limited shift and complex rotation.
opposed or adducted with MCP and IP extension throughout In-hand manipulation skills develop after primary grasp and
the shift. The object usually is held solely on the radial side of release skills have matured. By approximately 12 to 15 months
the hand. Examples of this skill are separating two pieces of of age, infants use finger-to-palm translation to pick up and
paper, moving a coin from a position against the volar aspect “hide” small pieces of food in their hands. By 2 to 2.5 years of
of the DIP joints to a position closer to the fingertips (e.g., to age, children use palm-to-finger translation and simple rotation
insert a coin into the slot of a vending machine), and adjusting with some objects.99 Complex rotation skills are observed in
a pen or pencil after grasp so that the fingers are positioned children at 2.5 to 3 years of age, although children of this age
close to the writing end of the tool. This skill is used frequently group often have difficulty with them. By 4 years of age, chil-
in dressing tasks such as buttoning, fastening snaps, lacing dren consistently use complex rotation without using an exter-
shoes, and putting a belt through belt loops. nal support.100 Children between 3.5 and 5.5 years of age

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 CHAPTER  8  Hand Function Evaluation and Intervention 227

develop skills in rotating a marker (regardless of its initial ori-

entation) and shifting it into optimal position for coloring and
writing.69 Children 3 and 3.5 years old demonstrate shift,
although use is inconsistent.43
After 3 years of age, a child’s in-hand manipulation skills
become more proficient and consistent. For example, objects
are seldom dropped during in-hand manipulation tasks.98
In-hand manipulation speed and accuracy continue to improve
during the preschool years. By 6 years of age children develop
the ability to use a variety of in-hand manipulation skills with
stabilization.97 Between 6 and 7 years of age, children more
consistently use combinations of in-hand manipulation skills in
complex fine motor activities (e.g., palm-to-finger translation
with stabilization followed by complex rotation with stabiliza-
tion). These skills continue to refine and speed improves
through 12 years of age, at which time skills are similar to those FIGURE 8-5  A 10-month-old infant exhibits object release
of adults.55 with full finger extension.
Object characteristics influence the in-hand manipulation
pattern used. In general, medium-sized objects (e.g., standard
crayons) are easier for children to manipulate than slightly
larger objects (e.g., larger-diameter crayons) or tiny objects.
Tiny objects require precise fingertip control, whereas medium-
sized and larger objects require control with more fingers.
Other factors that contribute to a child’s use of in-hand manip-
ulation skills include the cognitive-perceptual demands of the
activity and the objects’ shape and texture. The child’s motor-
planning skills, strength, and tactile sensibility can influence
development of in-hand manipulation skills.

Voluntary Release
Voluntary release, like grasp, depends on control of arm and
finger movements. To place an object for release, the arm must
move into position accurately and then stabilize as the fingers FIGURE 8-6  A 2-year-old exhibits precision release with
and thumb extend. Object release requires precise coordination partial finger extension.
of fingertip forces and timing for predicting accurate object
placement (e.g., on a surface).60
Initially the infant does not voluntarily release an object; develops the ability to release objects into smaller containers
objects either drop involuntarily from the hand or must be and to stack blocks. The release pattern is refined over the next
forcibly removed from the hand. As the infant’s tactile and few years until the child can release small objects with graded
proprioceptive perception, eye-hand coordination, and cogni- extension of the fingers, indicating control over the intrinsic
tive development improve, volitional control of release emerges. hand muscles (Figure 8-6). Between 7 and 13 years of age,
The infant first demonstrates object release when transferring children acquire effective modulation of fingertip force when
objects from one hand to another. Initially the child stabilizes grasping lighter and heavier objects to accurately time their
the object in the mouth during transfers or pulls it out of one release and placement.39,97 Development of precision release,
hand with the other. By 5 to 6 months the infant transfers the similar to precision grasp, illustrates the integration of percep-
object from one hand to the other by fully opening the releas- tual, motor, cognitive, and sensory functions.
Copyright © 2014. Elsevier. All rights reserved.

ing hand.
By 9 months of age the infant begins to release objects
without stabilizing them with the other hand. Typically, the Bimanual Skills
arm (i.e., elbow and wrist) extends during release. The infant In typical development the infant gradually learns to use both
exhibits increasing shoulder control as he or she moves the arm sides of the body together in effective ways and to use each
to drop objects in different locations. With the development of side of the body independently of the other. Initially the
dissociation of arm and hand and increasing elbow stability, the newborn moves his or her arms in asymmetrical patterns that
infant begins to release with the elbow in mid ranges (i.e., with are not coordinated. Movements of one arm often elicit reflex-
some degree of flexion). To control release, the child may ive, nonpurposeful reactions in the other arm. Gradually the
stabilize the arm or hand on the surface during release. At infant develops the ability to move the two arms together in
about 1 year of age, the child can release objects with shoulder, the same pattern. As skilled use of symmetrical hand and arm
elbow, and wrist stability; however, the MCP joints remain patterns is refined, the infant begins to use the two arms
unstable during this pattern, therefore the infant continues to independently of one another to perform different roles in an
show excess finger extension (Figure 8-5). Gradually the child activity.27,47,48 For example, one hand stabilizes an object while

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 228 SECTION  III Occupational Therapy Intervention: Performance Areas

the other hand manipulates it. Overflow and associated move- Figure 8-7). Effective stabilization of materials also depends on
ments gradually decrease to allow separate but coordinated adequate shoulder, elbow, and wrist stability.
action of the two hands. Between 18 and 24 months of age, the child begins to
As discussed previously, infants progress from asymmetry to develop skills that are precursors to simultaneous manipulation.
symmetry to differentiated asymmetrical movements for bilat- Continuing development of reach, grasp, release, and in-hand
eral hand activities. Asymmetry is a characteristic of movement manipulation skills complements bimanual skill refinement.
patterns until almost 3 months of age. Symmetric patterns Skills in visual-perceptual, cognitive, and motor areas become
predominate between 3 and 10 months of age, when bilateral more integrated, leading to the child’s effective use of motor
reach, grasp, and mouthing of the hands and objects are planning for task performance. Simultaneous manipulation
primary activities. Control of these movements originates prox- using both hands together—that is, opposing hand and arm
imally at the shoulders, allowing the hands to engage at midline. movements for highly differentiated activities (e.g., cutting
By 9 to 10 months of age the infant can hold one object in with scissors)—emerges at about 2.5 years of age.27,47 This
each hand and bang them together. This ability to hold an mature pattern is refined, including increases in speed and
object in each hand at the same time is critical for further efficiency, as the school-age child engages in increasingly
bimanual skill development. By 10 months of age bimanual complex manipulation tasks.
action is well differentiated, with one hand grasping the object
and the other exploring parts of it (Figure 8-7).48,49
Differentiated bimanual action, first as reciprocal or alternat- Ball-Throwing Skills
ing hand movements, then as simultaneous hand movements, Ball-throwing skills reflect the child’s ability to use shoulder
allows the child to engage in ADLs and object interactions of strength and control with release skills. In throwing a small
increasing complexity. By 17 to 18 months of age, infants ball, the child must sequence and time movements throughout
frequently use role-differentiated strategies (i.e., one hand sta- the entire upper extremity. The child brings the arm into a
bilizes or holds the materials and the other manipulates or starting position, then prepares for projection of the ball into
activates them).17 For these skills to emerge, the infant must space by moving the trunk with the scapulohumeral joint,
be able to dissociate the two sides of the body and begin to stabilizing the shoulder while beginning to extend the elbow,
use the two hands simultaneously for different functions (see stabilizing the elbow while moving the wrist from extension to
a neutral position, and simultaneously forcefully extending the
fingers and thumb.
Children progress through a series of skill levels before they
can smoothly sequence these movements and project the ball
to the desired location. Research on the development of ball-
throwing skills is quite limited and has primarily been identified
in the context of standardized test development.12,54 By 2 years
of age the child can throw a ball forward and maintain balance
so that his or her body does not also move forward. At this age
the child uses arm extension without sustained shoulder flexion
to fling the ball.54 The child dissociates trunk and arm move-
ment but does not completely dissociate humeral and forearm
movements. By 2.5 to 3 years of age, the child projects the ball
approximately 3 feet forward toward a target. This ability to
control the direction of the ball to some degree implies that
the child can control the humerus so that the elbow is in front
of the shoulder when the ball is released. Thus the shoulder
has sufficient stability to support controlled elbow and finger
movement. By 3.5 years of age, the child throws a ball 5 to 7
feet toward a target with little deviation from a straight line.54
To accomplish this level of throwing accuracy, the child posi-
Copyright © 2014. Elsevier. All rights reserved.

tions his or her elbow in front of the shoulder before releasing

the ball.
Further refinement of ball-throwing skills continues over the
next few years. Distance and accuracy improve as the child gains
scapulohumeral control, the ability to sustain the humerus
above the shoulder, and the ability to control the timing of
elbow, wrist, and finger extension. Thus at approximately 5
years of age, the child uses an overhand throw to consistently
hit a target at 5 feet. Children between 6 and 7 years of age
can hit a target 12 feet away using an overhand throw.54 Chil-
dren 5 years of age or older also use underhand throws to
FIGURE 8-7  This 10-month-old shows emerging bimanual contact a target. Underhand throwing requires the ability to
skills with one hand holding the object and the other manip- move the humerus into flexion while sustaining full external
ulating it. rotation.

Case-Smith, J., & O'Brien, J. C. (2014). Occupational therapy for children and adolescents. Retrieved from http://ebookcentral.proquest.com
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 CHAPTER  8  Hand Function Evaluation and Intervention 229

C
FIGURE 8-8  A 2-year-old experiments with using a marker (A and B) and a crayon (C),
exhibiting a variety of transitional grasping patterns.

the child demonstrating a high level of attention to his or her

Tool Use action to performing at a more automatic level. With practice,
Tool use is part of everyday life and is an essential method performance becomes faster, more accurate, and smoother (i.e.,
for children and adults to interact with their environment. It more automatic), resulting in proficient tool use for daily life
involves purposeful, goal-directed manipulation of a tool to tasks (Figure 8-8, A to C).
interact with other objects or materials.26,105 Proficient tool use The first tools that a child learns to use with proficiency are
is essential to participation in a variety of self-care, play and those required for eating. A toddler uses a spoon by 18 months
leisure, and school and work tasks. Tool use competence for of age, a fork by 2.5 years of age, and a knife by 6 years of age.65
eating and play typically emerges during the second year, after In a longitudinal study on development of spoon use skills in
the child has mastered the basic skills of reach, grasp, and infants between 11 and 23 months of age, 17- to 23-month-
Copyright © 2014. Elsevier. All rights reserved.

release.27 These skills emerge concurrently with in-hand manip- old toddlers showed a clear hand and grasping pattern26 prefer-
ulation skills that allow the tool to be dynamically held with ence for eating. Between these ages, children used 10 different
fingers adjusting it within the hand. grasp patterns, none of which was typical of an adult pattern.
A child’s acquisition of tool-use skills highly relates to cogni- The most commonly used pattern was a transverse palmar grasp
tive development. In proficient tool use, an individual under- with all four fingers flexed around the handle of the spoon. By
stands the goal of the task (the intentional aspect of the task) 17 months toddlers held the spoon primarily in their fingers
and knows how to accomplish it (the operational aspect of the and used some degree of finger extension to hold and orient
task).82,105 Acquisition of tool use follows the stages of motor the spoon. This pattern, which continues to refine through the
learning (later defined in the motor learning section). Initially, second year, improves eating efficiency.
the child experiments with a tool (e.g., a marker) by trying a Another example of tool use that emerges in young children
wide variety of actions (e.g., holding in either hand, with fist is cutting with scissors.54 Early cutting is actually snipping, a
or fingers, at top or base of marker). Experimenting with a tool process of closing the scissors on the paper with no movement
is an important stage in the skill-acquisition process. As skill of the paper and with no ability to repetitively open and close
acquisition progresses, practice allows the skill to progress from the scissors while flexing the shoulder and extending the elbow

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 230 SECTION  III Occupational Therapy Intervention: Performance Areas

TABLE 8-2 Developmental Sequence for Scissors Skills

Age (years) Scissors Skill Arm Actions

2 Snips with scissors Hand holding paper is minimally involved; may hold paper awkwardly or with
lateral pincer; hand with scissors often pronated.
2.5 Cuts across a 6-inch piece Hand holding paper in active supination; holds paper with stability; hand with
of paper scissors supinated.
3 to 3.5 Cuts on a line 6 inches long Hand holding paper with stability, forearm in partial supination; hand holding
scissors supinates to 90 degrees.
3.5 to 4 Cuts out a circle* Hand holding paper moves it in coordination with cutting; hand holding scissors
is supinated 90 degrees or more.
4 to 5 Cuts out a square Hand holding paper moves it in coordination with cutting; hand holding scissors
is supinated 90 degrees or more.
6 to 7 Cuts a variety of shapes Both hands cooperate in synchronous and reciprocal interaction during cutting
actions.

*The research of Rodger, Ziviani, Watter, Ozanne, Woodyatt, & Springfield (2003) suggests that cutting a circle is more difficult than cutting a square.
Adapted from Folio, R. M., & Fewell, R. (2000). Peabody developmental motor scales—revised. Chicago: Riverside.

to move across the paper. Three-year-old children may use a influenced by the task demands; for example, 18- to 36-month-
pronated forearm position or a forearm-in-mid-position place- old infants show a preferred hand in bimanual manipulation
ment, or they may alternate between the two forearm positions. tasks that mandate a dominant hand but not in simple grasping
By 4 years of age children typically hold both forearms in mid tasks. When exploring objects, infants tend to use both hands
position for the cutting activity.92 Table 8-2 describes the and not demonstrate a preferred hand.49
typical sequence for the development of scissors skills. Hand preference continues to develop until at least 8 years
The child’s grasp on the scissors changes over time. The of age, as illustrated in a study of a reaching activity that
thumb position in one hole remains consistent, but the finger involved crossing the midline of the body. Carlier, Doyen, and
positions change according to the child’s level of maturation Lamard15 found that with increasing age, children used the
and the type of scissors used. Although grasp pattern is deter- preferred hand with greater frequency to pick up cards in
mined by the type of scissors, by 6 years of age a child dem- various locations, including crossing the midline with the pre-
onstrates a mature grasp with the ulnar two fingers flexed ferred hand. As with other areas of hand skill development,
(inside or outside the lower hole, depending on its size) and some degree of variability and inconsistency is the typical
the radial fingers within the top scissor hole to provide the pattern for young children. It is worrisome and atypical when
cutting action. infants (less than 7 months) consistently use one hand, and
One component of tool use is the role of the assisting hand. these infants should be further evaluated for possible neuro-
For example, in using scissors and eating, the assisting hand logic impairment.
has an active role, while in writing and drawing, the assisting
hand primarily stabilizes the paper. In cutting, the assisting
hand holds the paper and orients it using rotational movements Relationship of Hand Skills to
in the same or the opposite direction as the hand with the scis- Children’s Occupations
sors. In eating, the child’s assisting hand may be involved in a
variety of activities, depending on the child’s age and the uten- Hand skills are vital to the child’s interaction with the environ-
sils used. Infants between 18 and 23 months of age appear to ment. Engagement in most occupations requires object and
have significantly more involvement of the assisting hand in material handling with one’s hands.
stabilizing a dish during spoon feeding than do infants between
12 and 17 months of age.26
Copyright © 2014. Elsevier. All rights reserved.

Play
Although infants engage with people and objects through their
Hand Preference visual and auditory senses, these are distant senses and do not
Hand preference, sometimes termed hand dominance, is a readily bring the infant essential information that can be gained
complex concept. In typical children hand preference evolves only through touch. In early exploratory play with objects, an
over a long period of time and gradually becomes more con- infant learns object properties through manipulating them.17,117
sistent, as do other expressions of motor functioning. In chil- The interaction of touching, grasping, and manipulating, while
dren 6 to 24 months of age, use of a preferred hand is visually inspecting, allows the infant to integrate sensory infor-
inconsistent in about 60% of the children performing a simple mation and to learn that objects remain the same regardless of
grasp task. When one hand is used as a stabilizer and one as a visual orientation.
manipulator, 65% or more of the children over 18 months use With increasing age, until at least the early school years,
the right hand as the manipulator. Inconsistency of preferred participation in play depends on hand function and fine motor
hand was noted in some children in the 2.5- to 3-year-old skill competence. These skills are reflected in the child’s
group but not in the 4-year-old group. Handedness is highly interest in activities such as cutting with scissors, dressing and

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 CHAPTER  8  Hand Function Evaluation and Intervention 231

undressing dolls, putting puzzles together, constructing with building materials, and puzzles, and participate in simple
various types of building materials and model sets, participating cooking and art projects. During kindergarten and the early
in sand and water play, completing craft projects, and engaging elementary school years, children use fine motor skills most of
in imaginary play with objects. Playing video games and using the school day. McHale and Cermak89 found that first and
computers also require fine motor control. Dramatic play second grade children spend 45% to 55% of the school day
with dolls or figurines in doll houses and vehicles involves engaged in fine motor activities. Fourth grade children spend
precision hand movement including in-hand and bimanual approximately 30% of their school day participating in fine
manipulation. motor activities, primarily paper-pencil tasks. Writing activities
include preparing one’s paper, obtaining a writing tool, and
using an eraser. Other typical fine motor activities in children’s
Activities of Daily Living classrooms include cutting with scissors, folding paper, using
Activities of daily living (ADLs) often entail a sequence of steps paste and tape, carrying out simple science projects, assuming
using a variety of hand functions. Specific hand functions responsibility for managing one’s own snack and lunch items,
needed for ADLs include (1) precision and power grasps of and organizing and maintaining one’s desk.28 Elementary
objects and materials; (2) complementary and reciprocal school children also need computer and keyboarding skills to
bimanual skills; (3) hand movements, including in-hand function in the classroom.
manipulation, with and without vision; (4) complex action Older children and adolescents use high-level fine motor
sequences; and (5) development of automaticity.65 In-hand skills for science projects, vocational courses (e.g., woodwork-
manipulation speed, grasp strength, motor accuracy, and tool ing, metal shop, and home economics), art classes, music
handling are correlated with self-care skill development.16 classes (other than vocal music), managing a high volume of
Dressing skills (i.e., donning shirts, pants, socks, and shoes) written work and notebooks, keyboarding, and maintaining a
involve complex grasping patterns and in-hand manipulation locker. Greater speed (e.g., in writing and keyboarding) and
skills to fasten and a variety of bimanual skills to manipulate greater strength (e.g., for physical education and vocational
the clothing. Donning jewelry requires the ability to use deli- courses) are required. As demands in high school increase,
cate grasp patterns and in-hand manipulation. Bathing, show- proficiency and speed in using keyboards, calculators, and
ering, and other personal hygiene skills depend on the child’s writing utensils is expected. Children and adolescents with
increasing control of dynamic grasping patterns to handle slip- hand function difficulties often demonstrate limited productiv-
pery objects (e.g., soap). In addition, these skills are likely to ity and require accommodations for written communication
be needed when an individual is in a standing position, such as tasks, managing school-related materials, and manipulating
when putting toothpaste on a toothbrush, brushing the teeth, learning materials.7
shaving, or applying makeup. Youth need high competency in
precision grasp, in-hand manipulation, and dynamic tool use
to perform complex hygiene activities such as shaving, applying Evaluation of Hand Skills in Children
makeup, using tweezers, cutting nails, and styling hair (apply-
ing barrettes or rubber bands and using a curling iron, a brush, The developmental sequence provides a backdrop for evalua-
and a hair dryer). tion of hand function. The occupational therapist evaluates a
Eating skills require refinement of the ability to use forearm child’s hand skills in the context of play, self-care, and school
control with a variety of grasp patterns and tools. The ability occupations when the evidence suggests that problems with
to use both hands together effectively is necessary for spreading performance are associated with delays or impairment in hand
and cutting with a knife, opening all types of containers, function. Based on the evaluation purpose, a variety of stan-
pouring liquids, and preparing food. In-hand manipulation dardized and non-standardized assessments can be used (see
skills are used to adjust eating utensils and finger foods within Chapter 6). Parents, teachers, and the child often are the best
the hand, to handle a napkin, and to manipulate the opening sources of information about difficulties with participation at
of packaged food and utensils. home and in the community; this information is obtained
Typically developing children 8 years of age and older are through the development of an occupational profile.
independent in self-care skills and the manipulation skills When a problem with occupational performance that implies
required to perform eating, dressing, and hygiene tasks. In hand function delays has been identified, the occupational
Copyright © 2014. Elsevier. All rights reserved.

contrast, children with DCD and poor coordination are fre- therapist plans a full evaluation of fine motor, visual-motor, and
quently delayed in development of dressing, personal hygiene, hand function performance. To fully analyze hand function and
toileting, and independent eating skills.91,108 Older children potential reasons for difficulties, related performance areas
with DCD perform similarly to younger typical children. may need to be screened and/or assessed using standardized
Because older children with DCD demonstrate delays in self- methods. Postural alignment and stability, gross motor skills,
care, parents continue to support their self-care participation cognitive and perceptual skills, sensory processing, social skills,
by providing cues, assistance, and substitutions.108 and emotional functioning are associated performance areas
that can contribute to hand function.
Analysis of the identified hand function problems follows
School Functions administration of specific assessments or scales that define the
Independent functioning in the school environment requires basis of the problem and the extent of the impairment. A
effective hand function and competence in fine motor skills. sample analysis of an occupational performance problem in the
In preschool classrooms, children engage in a variety of manip- area of constructive play associated with delayed and impaired
ulative activities, for example, using crayons, scissors, small hand function is presented in Box 8-1. The occupational

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 232 SECTION  III Occupational Therapy Intervention: Performance Areas

therapists administer a combination of standardized assess-

BOX 8-1 Analysis of Performance
ments. Examples of measures used in comprehensive evaluation
Components Potentially Associated
of hand function are listed in Table 8-3.
with Delays or Impairment in
Constructive Play
Occupational therapists apply clinical reasoning to analyze Intervention Models, Principles,
potential reasons for a child’s delay or limitation in construc- and Strategies
tive play activities. Constructive activities vary by the child’s
age and may include completing puzzles, building with blocks Occupational therapists use a variety of evidence-based practice
and Legos, stacking toys, and participating in games that models to guide interventions to improve a child’s hand func-
involve moving and combining small objects. When the tion. The child’s diagnosis (e.g., cerebral palsy, developmen-
basis for a child’s performance delay is identified, these tal coordination disorder), severity of involvement (e.g., mild,
components can be targeted in designing play activities for
moderate, severe), context for intervention (e.g., clinic, home,
intervention.
school), service delivery model (e.g., direct, consultation), and
1. Delayed or limited in-hand manipulative skills may be
associated with: phase of intervention (e.g., preparation, practice, generalization)
a. Unstable wrist in neutral position or extension, uses influence which practice approach is used. Practice models used
wrist flexion by occupational therapists to improve children’s hand function
(1) Decreased tone in wrist extensors can be categorized as biomechanical/neurodevelopmental,
(2) Increased tone in wrist flexors occupation-based, and adaptation/ecologic and are described
b. Unstable metacarpophalangeal (MCP) joints and lim- in the following sections. These practice models, with their
ited stability of finger joints corresponding principles and strategies, are generally used in
(1) Increased tightness of extensor digitorum muscles combination or sequentially throughout a course of interven-
c. Inability to identify finger being touched; decreased
tions to improve a child’s hand function.
tactile discrimination
d. Lack of midrange movements of finger joints
(1) Poor co-contraction of MCP and interphalangeal Biomechanical and
(IP) flexors and extensors
(2) Tightness in intrinsic muscles and long finger
Neurodevelopmental Approaches
flexors Practice models that focus on the child’s musculoskeletal and
2. Breaking materials, often by dropping and crushing them, neuromotor systems are considered to be bottom-up approaches
may be associated with: because they focus on enhancing specific components of per-
a. Inability to sustain finger pad grasp; may be associ- formance. The approaches are based on an understanding of
ated with: normal movement patterns and body alignment and incorpo-
(1) Poor tactile or proprioceptive awareness
rate handling and positioning of the child to inhibit and
(2) Poor co-contraction of muscle groups
facilitate posture and movement. The occupational therapist
b. Excessive finger flexion in grasp may be associated
with: embeds these techniques in specific activities that promote
(1) Poor proprioceptive awareness of size and weight strengthening and motor control of targeted movements.
of object These approaches require careful, in-depth analysis of perfor-
(2) Increased finger flexor tone mance to identify missing, atypical, or delayed body functions
(3) Associated reactions that are the basis for hand function problems. Biomechanical
(4) Inactivity in intrinsic muscles approaches focus on the musculoskeletal system, including
3. Ineffective bilateral handling may be associated with: spinal alignment, joint alignment throughout the body, muscle
a. Weakness and limited control of movement in one arm tone, and muscle strength as foundational elements of a child’s
and hand
motor skill. In neurodevelopmental therapy, therapists use
(1) Unstable grasp because of poor wrist extension
facilitation and inhibition handling techniques within activities
caused by increased flexor tone
(2) Learned nonuse of one hand designed to enhance the child’s motor control.
b. Delays in bimanual coordination, reciprocal and simul-
Biomechanical Practice Model
taneous use of two hands together
Copyright © 2014. Elsevier. All rights reserved.

(1) Difficulty in motor planning of sequential, coordi- The biomechanical approach or practice model is used primar-
nated movements ily to assess and provide intervention activities that improve a
(2) Limited or inaccurate tactile and kinesthetic feed- child’s ROM, strength, or endurance. Biomechanical approaches
back from arm and hand movement. focus on postural alignment, joint stability and relationships,
(3) Delays in performance of cooperative, precise hand and musculoskeletal problems. For example, biomechanical
and finger movements, possibly related to delayed
principles explain the basis for tenodesis grasp (i.e., automatic
somatosensory or visual motor integration.
finger flexion when the wrist is extended) and the relationship
of intrinsic and extrinsic muscle control for grasp and in-hand
manipulation patterns.
therapist analyzes potential sensory, musculoskeletal, and neu- Types of Children Who Benefit from
romotor functions that may contribute to a child’s difficulties Biomechanical Approaches
in construction activities. To support analysis of the child’s Children with musculoskeletal and neuromotor disorders asso-
performance in specific tasks and interpret which sensory, ciated with prenatal or perinatal central nervous system lesions
motor, perceptual, and cognitive factors influence performance, or anomalies often receive interventions that use biomechanical

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 CHAPTER  8  Hand Function Evaluation and Intervention 233

TABLE 8-3 Comprehensive Hand Function Evaluation

Evaluation Objective Examples of Tools

Measurement of active and passive range of motion (ROM) Goniometer

Observation of ADL tasks
Evaluation of strength Muscle testing (modified for children)
Grip and pinch strength testing
Observation of strength and endurance across motor tasks
Evaluation of tactile perception/sensibility Two-point discrimination40
Finger identification with vision occluded
Stereognosis Identification of common objects with vision occluded
Matching of object in hand (with hand behind barrier) to one
visualized
Postural alignment and postural stability Observation of posture when trunk is unsupported.
Postural tilt with observation of equilibrium responses.
Classification of hand function to document outcomes Manual Abilities Classification System (MACS)41
Assessment of developmental hand skills in young children Bayley Scales of Infant and Toddler Development (3rd ed.):
Motor Scale5
Peabody Developmental Motor Scales (2nd ed): Fine Motor54
Hawaii Early Learning Profile: Fine Motor97
Assessment of fine motor coordination in older children and Bruininks-Oseretsky Test of Motor Proficiency (BOT-2)12
adolescents Purdue Pegboard Test
Box & Block Test of Manual Dexterity85
Test of In-Hand Manipulation101
Assessment of quality of movement and dissociated movement Quality of Upper Extremity Skills Test (QUEST)32,33
patterns (for children with cerebral palsy)
Assessment of visual motor integration Developmental Test of Visual Motor Integration (5th ed.) (VMI)8
Developmental Test of Visual Perception (DTVP-3)64
Assessment of bimanual hand function Assisting Hand Assessment74
Melbourne Assessment of Unilateral Upper Limb Function104
Assessment of hand function for prevocational or work tasks Job task simulations

approaches. Primary features of neuromotor disorders such as extremities. These movement problems are associated with
cerebral palsy are abnormal muscle tone, muscle weakness, and poor postural alignment and significantly delayed motor skill
sensory loss. Muscle tone may be lower or higher than the development.
normal muscle tension (e.g., hypotonia or spasticity) and is Biomechanical Model Principles and Strategies
associated with shortening and tightness of muscle groups Biomechanical approaches consider postural alignment, pos-
and malalignment or contracture of joints. With imbalance of tural stability, the level of motor skill performance, effects of
muscle groups around joint structures, upper extremity joints gravity, effects of the supporting surface, and the most efficient
can tighten into a position of flexion or extension that counters postures for functional performance. Biomechanical approaches
full hand function. for children with cerebral palsy and neuromotor disorders as
The biomechanical problems associated with hypotonia described previously often focus on minimizing spinal asym-
include poor postural stability that affects hand function in a metries and optimizing support of posture. Box 8-2 defines key
seated or standing position and poor control of arms in space concepts of the biomechanical approach. The occupational
(i.e., when posture is unsupported). Therefore, children with therapist often implements biomechanical techniques that
hypotonia may need seating supports such as a high chair back, support optimal function before making activity demands on
Copyright © 2014. Elsevier. All rights reserved.

lateral supports, firm seating, and strapping to maintain a the child or before need for performance. Principles and exam-
midline, upright posture when sitting in a chair or wheelchair ples for the biomechanical model are listed in Table 8-4.
to effectively use their arms and hands. When children with In selecting the positioning of the child for hand function
cerebral palsy have spasticity, they exhibit limited ROM, interventions, the occupational therapist must consider the
stiffness that restricts movements, asymmetrical postures and optimal position for eliciting the particular skills desired, given
movements, and difficulty maintaining upright postures. Arm activity demands and environmental contexts. Positions are
and hand function is often limited to small ranges of movement carefully selected and optimally supported to promote the
with reduced isolated thumb and finger movements and limited child’s alignment, postural stability, and control of arm and
control of their arms when not stabilized on a surface. Children hand movements. Supported side-lying, prone, sitting, or
with spastic quadriparesis may exhibit primitive reflexes, such standing may be optimal positions to elicit and practice fine
as the asymmetrical tonic neck reflex, and stereotypical patterns motor skills. For example, a child with significant weakness or
of movement (e.g., a pattern of pronation, elbow, wrist, and spasticity may achieve hands-to-midline or reach only in the
finger flexion when bringing hands to mouth). Patterns of hip side-lying position. The side-lying position may reduce the
adduction and internal rotation may dominate in the low effects of gravity on overall body posture and may make it

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 234 SECTION  III Occupational Therapy Intervention: Performance Areas

BOX 8-2 Biomechanical Model Concepts

Range of Motion (ROM) Alignment of the Body

ROM requires joint movement and flexibility. Strength and The alignment of shoulders, pelvis, and feet is influenced by
coordination of arm movement relates to ROM, and optimal gravity. Body alignment reflects the interaction of gravity, pos-
position for function is usually midrange of the joint. Joints tural tone, position, and supporting surfaces. Alignment of the
may be limited in ROM because of muscle tightness, soft tissue trunk influences the possible ROM and control of head, arms,
contracture, or fascial restrictions. and legs.

Base of Support Muscle Strength and Postural Control

The body’s base of support includes the areas of the body that The musculoskeletal system maintains posture and movement
are in contact with the supporting surface. The center of pres- through muscle force (muscle fiber activation). Postural control
sure in standing or sitting depends on the characteristics of the requires spinal alignment, muscle tone (active muscle tension),
base of support. Postural activity is initiated at the base of and muscle strength.
support (e.g., when sitting, pelvic movement allows the trunk
to shift forward or laterally for reach). Mobility
Changes in the base of support influence alignment of the Movement of the body through space requires postural control,
spine and limbs. muscle strength, and muscle control.

Adapted from Adolph, K.E., Vereijken, B., & Shrout, P. E. (2003). What changes in infant walking and why? Child Development, 74(2), 475–497.

TABLE 8-4 Biomechanical Model Principles and Examples

Principles Description and Examples

Optimal positioning of the child includes natural The child’s head is aligned over the pelvis. When the child is in a prone
spinal alignment with trunk stable or well stander, head and pelvis are aligned over the feet. A straight line can
supported. be drawn from head to feet.
Central control at shoulders and pelvis is prerequisite The pelvis anchors the trunk and provides a base of support for shoulder
to control of arm and hand movement in space. and arm movement. The shoulder and scapula complex anchor the
arms’ movement in space and allows for rotational movement in
reach and carry.
Postural control is influenced by the child’s postural When sitting square on buttocks on a firm surface, postural tone is likely
tone, spinal alignment, and gravity and to be neutral with extension against gravity dominating.
supporting surfaces.
Midline position of the head, arms, and hands is Many positioning devices facilitate midline position of head and arms.
optimal for most functional tasks. Lateral supports on a wheelchair or feeder chair can guide arms to
midline.
Equipment to support a child’s alignment and trunk A firm seat such as that of a Rifton chair or wheelchair allows the child
control should be firm, stable, and solid. to sit in a neutral pelvic position (i.e., square on buttocks). A firm
seat can prevent adduction of hips and reduce posterior pelvic tilt.
For optimal function, a child should feel stable, able Strapping on a wheelchair should allow weight shift, movement of
to move against gravity, able to shift weight, and arms, and reach in all directions. For optimal function, the child sits
able to flexibly adjust his or her position when with dynamic stability and can move his or her arms overhead and
needed. across the midline.
For optimal function, the child’s postural tone should A child’s postural tone may be optimal when sitting on a firm surface,
be relaxed, allowing him or her to actively when feet are well supported, and when a midline position is
maintain upright posture and flexibly maintain facilitated. See Chapter 20 for additional information on seating and
functional postural alignment. positioning.
Copyright © 2014. Elsevier. All rights reserved.

possible for the child to more easily open his or her hands. the forearms can elicit and reinforce shoulder stability and
However, side-lying positions tend to limit most hand func- co-contraction, dissociation of the two sides of the body during
tions, and in general children exhibit more varied and skillful weight bearing on one arm while manipulating with the other,
hand function in supported sitting positions. bilateral manipulation of objects, and visual regard of the
The occupational therapist can use certain body positions hands. By placing a child prone on a wedge, the effect of gravity
to elicit specific hand skills. The supine position is effective for is reduced, allowing for more trunk and next extension. Prone
working with infants on initial control of arm movements with positioning can be an advantageous position for the child to
visual regard of the hands during movement. Supine position- visualize his hands but limits the child’s viewing of the environ-
ing can be used to reinforce midline movements of hands and ment. Use of prone positioning for play activities is always
reach against gravity; however, a supine position is not func- fatiguing and should be used only for brief periods with the
tional for most activities and is most appropriate for infants (less occupational therapist or caregiver present to support the
than 12 months). A prone position with weight bearing on child’s actions.

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 CHAPTER  8  Hand Function Evaluation and Intervention 235

Through assessment of the child’s alignment, postural the just-right support for a child to competently perform fine
control, and arm/hand control, the occupational therapist motor activities.113 In a systematic review of the effect of posi-
identifies and recommends positioning and seating that offer tioning on upper extremity function, Stavness121 found that
sufficient stability and mobility for optimal hand function upper extremity function was optimal when the child was in a
across a range of home and school activities. For optimal hand functional sitting position with slight (0 to 15 degrees) forward
use in sitting, the child needs a chair that provides appropriate orientation, a pelvic strap, footrests, and a cutout tray. Care­
shoulder, pelvis, leg, and foot support.24,113 Even young chil- givers of children with cerebral palsy report that adapted seating
dren without motor disabilities benefit from sitting in furniture is useful to their families and enables the child’s participation
that fits appropriately. Children demonstrate higher level in important everyday activities.107 Rigby and colleagues107
manipulation skills when seated in chairs and at a table fitted found that adaptive seating was particularly important to the
to them than when seated in chairs and at a table that do not child’s ability to participate in eating, self-care, play, and recre-
fit. Appropriately fitted furniture may enhance hand function ational activities. Case Study 8-1 illustrates use of the biome-
by supporting proximal stability, thereby allowing the child to chanical approach to improve hand function in a child with
focus more on the manipulative tasks and less on postural spastic cerebral palsy (Figure 8-9).
readjustments.129 In addition to supportive and functional seating, children
To promote optimal alignment and control of hand func- with neuromotor disabilities may benefit from a wheelchair tray
tion for children with disabilities, adapted seating and position- in supporting the upper extremity during fine motor activities.
ing may be needed. When in a seated position, the child should For optimal support, the tray or table surface should be only
be able to shift weight in the anterior-posterior and lateral slightly above elbow height, because a lower table may cause
directions; his or her trunk should be aligned over the pelvis trunk flexion and a higher surface can cause abduction and
or leaning slightly forward; and the pelvis and shoulders should internal rotation of the arms. The tray’s height can be adjusted
be stable. Spinal alignment with trunk stability and mobility to meet specific goals; for example, children with muscle weak-
is important to functional movement of the head and arms. ness more effectively reach and carry objects when the table
Examples of adaptations for sitting, such as lateral supports, or tray surface is at or slightly above elbow height. With this
pelvic straps, pelvic stabilizers, and chest harnesses, can provide biomechanical advantage, the child’s control in manipulating

CASE STUDY 8-1 Biomechanical Model for Child with Cerebral Palsy
Zeza with Spastic Quadriparesis The manual chair that the occupational therapist and
Zeza was 3 years old and had severe spastic quadriparesis. She family selected had the following features:
received occupational therapy each week through an outpa- 1. The back extended to the top of her head to support her
tient clinic; she also received occupational therapy in her early head in neutral and midline.
childhood program. She was dependent in all of her self-care 2. A neck support helped to align her head in midline but
skills. Her parents fed her most meals, although she indepen- did not prevent full head turning and neck ROM.
dently self-fed finger foods. She also drank from a sippy cup 3. Shoulder straps that gently maintained neutral, upright
with handles with minimal assistance. She did not sit inde- trunk.
pendently but she sat with minimal assistance when provided 4. A pelvic strap held her buttocks against the back of the
full back support. She used a Rifton chair in the early child- chair and maintained neutral pelvis.
hood program and is transported in an umbrella stroller. Her 5. Lateral supports helped to maintain her trunk in neutral.
occupational therapist discussed with the family the purchase 6. Arm rests that supported her arms in neutral forearm and
of a manual wheelchair that would offer her more support. wrist positions; the arm rests also supported a tray.
Recognizing that a wheelchair, if well-fitting and adapted to 7. A tray supported her arms and gave her a surface to stabi-
her postural needs, could become a more functional sitting lize her hand in fine motor activities.
device at home and school, the family agree to purchase a 8. A foot rest fully supported her feet with hips, knees, and
wheelchair that would replace the stroller. ankles at 90 degrees.
Copyright © 2014. Elsevier. All rights reserved.

The occupational therapist with the family selected a The new wheelchair offered positioning that increased her
manual wheelchair that offered features to support her posture function in hand function activities, including eating and use
and enhance hand function. The therapist and family selected of switches. The wheelchair enabled Zeza to achieve the
a new chair that would facilitate Zeza’s achievement of the established objectives. In her new chair, she more fully par-
following Individual Education Program goals: ticipated in the early childhood program including circle time,
1. Eat yogurt and other thickened foods using a spoon with story time, art, and snack. Although she did not sit in her new
enlarged handle and suction bowl with minimal support wheelchair all day, it was her optimal seating device for activi-
in grasping the spoon. ties that required her highest level hand function. Often a
2. Successfully activate her iPod or CD player using a button child’s well-fitting wheelchair, because it has adapted features
switch on her wheelchair tray. that support postural alignment, gives the child a biomechani-
3. Participate in circle time songs and activities by imitating cal advantage and is an optimal seating device for hand func-
the teacher’s gestures with arms and hands, turning to tion and fine motor activities.
greet her peers, and vocalizing when appropriate. See Figure 8-9 for an example of manual wheelchair.

Case-Smith, J., & O'Brien, J. C. (2014). Occupational therapy for children and adolescents. Retrieved from http://ebookcentral.proquest.com
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 236 SECTION  III Occupational Therapy Intervention: Performance Areas

FIGURE 8-10  A slanted surface for writing promotes wrist

extension and active grasping patterns.

was proposed by the Bobaths in the 1960s and has been widely
used by occupational and physical therapists since that time.
The Bobaths were innovative in their understanding of cerebral
palsy and the effects of abnormal muscle tone (e.g., spasticity)
on postural control and movement. They recognized that
spasticity interfered with normal movement patterns and that
inhibition of spasticity was important to improving a child’s
movement patterns. They also believed that through sensory
feedback, a child with atypical muscle tone and movement pat-
FIGURE 8-9  This manual wheelchair provides optimal sup-
terns could learn normal movement patterns. The goals of
ports for a child with spastic quadruparesis to effectively
therapeutic handling are to inhibit spasticity, facilitate more
participate in visual-motor and fine motor activities.
normal muscle tone, and guide the child with cerebral palsy in
using more normal movement patterns.66
Types of Children for Whom Neurodevelopmental
objects can increase. Another biomechanical advantage that Therapy Principles and Techniques Are Appropriate
supports hand postures for effective tool use and other hand The NDT practice model was specifically designed for children
functions (e.g., for writing or fine motor activities) is use of an with cerebral palsy who have abnormal muscle tone. The
elevated or slanted table or tray surface. An elevated surface, Bobaths characterized spasticity as tonic reflexes, muscle co-
such as a slant board positioned at an angle of 20 to 30 degrees, contraction, and stereotypic movement patterns and specified
can facilitate a hand position of wrist extension, increasing the that an important goal of therapy was to reduce spasticity and
child’s control of finger flexion for grasping activities92 (Figure its associated abnormal movement patterns. NDT theories and
8-10). Table 8-5 presents characteristics of optimal postural postulates have enabled occupational therapists to understand
support for fine motor tasks when sitting. how abnormal muscle tone, primitive reflexes, abnormal move-
For children with mild to moderate motor involvement, ment patterns, loss of strength, and impaired muscle synergies
standing may be an appropriate position for practice of fine interfere with motor control.66,125 By analyzing these compo-
motor activities. Standing facilitates extension through the nents of posture and movement in children with cerebral palsy,
Copyright © 2014. Elsevier. All rights reserved.

trunk and neck and may promote more active postural tone occupational therapists have conceptualized new methods to
when compared with sitting. Many daily living skills that rely improve these elements of the child’s motor function.
on hand skills, such as brushing the teeth, zipping and button- When a child has cerebral palsy, control of arms in reach
ing clothing, shaving, applying makeup, and cooking, are most and carry; development of precise hand and finger movements;
commonly done while standing. For children who have sub- bimanual coordination; and sequential, reciprocal, fluid move-
stantial difficulties with standing, the occupational therapist ment patterns are delayed, limited, or missing. Gordon and
should use this position only after the child has mastered the Duff 35,57,58 described the characteristics of hand function
skills in a sitting position. in children with cerebral palsy, explaining that they have
difficulty grading force and sustaining force during grasping,
Neurodevelopmental Therapy holding, and carrying objects. Children with cerebral palsy
Neurodevelopmental therapy (NDT) uses biomechanical prin- also have difficulty releasing objects with control and grading
ciples in addition to a range of handling and positioning tech- hand movements.60 The characteristics associated with cerebral
niques that promote motor function in children with cerebral palsy and related effects on hand function are described in
palsy. Originally termed neurodevelopment treatment, NDT Table 8-6.

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 CHAPTER  8  Hand Function Evaluation and Intervention 237

TABLE 8-5 Characteristics of Sitting Supports for Optimal Hand Function in Children with
Cerebral Palsy, Spastic Quadriparesis
Characteristic Rationale Example

The pelvis is supported on a solid Solid support promotes trunk symmetry and Chair seat is a firm cushion or
surface. trunk extension wooden surface.
The back support ends at the Support through the scapula area can enhance Most wheelchair backs end at the
scapula unless shoulder and shoulder stability for distal (hand) function. scapula, although chair backs can
head support is needed. extend to include head support.
A pelvic strap holds the pelvis in With hips at 90 degrees, the pelvis is upright or The strap holds hips at 90 degrees
place. The pelvis is in a neutral in a neutral position (without anterior or with a 45 degree angle across the
position and the hips are at 90 posterior tilt). A neutral pelvis supports an hips.
degrees. upright trunk.
The chair promotes symmetric Symmetric weight bearing results in symmetric Chair may include hip guides. A firm
weight bearing on thighs. posture, facilitating midline movement of seat also promotes symmetrical
arms and hand. weight bearing.
Knees and ankles are positioned Solid foot support anchors the lower extremity, Foot supports on wheelchair or other
at 90-degree angles. giving the trunk, head, and hands a firm chair that angle at 90 degrees.
base of support. When knees and ankles are A well-fitting chair seat that does not
at 90 degrees, muscle tone tends to be extend beyond knee angle.
neutral; tension on the hamstrings is
optimal; and a stable, neutral pelvis can be
maintained.
Lateral trunk supports can provide Lateral support guides the trunk but do not Lateral supports on wheelchair.
lateral stability and increase support or hold the trunk. Lateral supports Lateral supports on floor sitter or
midline alignment of trunk. can promote symmetry and midline. other chair.
A lap tray can improve shoulder A lap tray can provide a surface to support arms Wheelchair tray.
and trunk position. and hands.
A harness may be needed to A harness helps the child maintain an upright When fitting appropriately, most
promote an upright trunk and and symmetric posture. When using a harnesses firmly support the chest
to guide child’s weight shift harness, the child should be dynamically and pelvis while allowing the
when moving arms. stable (stable with mobility to move arms child to shift weight and reach.
and hands).

TABLE 8-6 Characteristics of Cerebral Palsy and Associated Hand Function Limitations
Characteristic of Cerebral Palsy Associated Hand Function Limitations

Muscle tone characterized by hyper- or Limited ROM at wrist, forearm, and fingers. In hypertonicity, the finger flexors may be
hypotonicity tight; the child cannot fully extend fingers.
In hypotonicity, the joints may be hypermobile and the hand lacks stability. Over time,
joints stiffen owing to limited or minimal joint movement.
Excessive co-contraction at joints (with Wrist, forearm, and metacarpals are stiff; wrist and finger joint movements are limited.
spasticity) Hand may tighten when child attempts to move fingers.
Copyright © 2014. Elsevier. All rights reserved.

Excessive thumb adduction.

Muscle synergies are inefficient and Flexor synergies may dominate upper extremity movement.
stereotypical These include shoulder internal rotation with elbow flexion, forearm pronation, and
wrist flexion.
Muscle weakness The hand may not have sufficient force to hold or move heavy objects. The hand may
not generate appropriate forces to hold and use writing utensils, scissors, eating
utensils.
Limited dissociated movement Fingers move together in full flexion or extension; child has difficulty moving isolated
fingers with control. Reciprocal, precise finger movements are limited.
Inability to initiate or sustain thumb opposition.
Intrinsic muscle action is limited.
Impaired sensory feedback Tactile, kinesthetic, and proprioceptive feedback is limited; sensory feedback is not
available to guide precise hand and finger movements

From Vogtle, L. K. (2006). Upper extremity intervention in cerebral palsy: A neurodevelopmental approach. In A. Henderson & C. Pehoski (Eds.).
Hand funciton in the child: Foundations for remediation (2nd ed., pp. 345–368). St. Louis: Mosby/Elsevier.

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 238 SECTION  III Occupational Therapy Intervention: Performance Areas

CASE STUDY 8-2 Use of Neurodevelopmental Therapy Techniques to Promote Hand

Function in a Young Child with Cerebral Palsy
Susan, 5-Year-Old with Spastic Quadriparesis side sitting. She moved into side sitting to the right and left
Susan was currently in regular kindergarten where she received to reinforce the trunk rotation patterns. Frequently the
special education, occupational therapy, and physical therapy. occupational therapists placed her in a prone position over a
She had a power wheelchair that gives her mobility in the therapy ball and rolled the ball forward to allow her to place
classroom and school. Susan spent 20 to 30 minutes each day her hands on the floor. This activity helped her develop full
in her prone stander and 30 minutes twice a day in her Rifton shoulder flexion range, equilibrium reactions in prone, and
chair. Most of the day she stayed in her power chair using the weight bearing on her hands.
tray that supports her fine motor activities. After these preparatory activities, often Susan elected to sit
The occupational therapist and physical therapist often in her Rifton chair with a tray. She practiced prehending and
worked together to provide NDT techniques in their clinic manipulating puzzle pieces to complete a puzzle with assis-
space. The occupational therapy goals were: tance from the occupational therapist supporting her shoul-
1. Given minimal physical assist at her shoulder, Susan will der, and she practiced using different switches to active her
use a spoon with enlarged handle and scoop bowl on her favorite toys. The occupational therapist gave her graded
wheelchair to feed herself applesauce. support, that is, the just-right support that she needed to
2. Given preparation using upper extremity weight bearing, accomplish the isolated (dissociated) arm and hand move-
Susan will demonstrate hand opening sufficient to turn ments. Although she held her hand in a more open position,
pages of her book. she continued to demonstrate difficulty in isolating and con-
3. Given preparation using upper extremity weight bearing trolling finger movements.
and trunk rotation, Susan will use her open hand to con- After the occupational therapy and physical therapy
sistently activate a button switch. session, the occupational therapists discussed with the teacher
Each session began with Susan lying on the mat, stretching Susan’s successes in completing the puzzles and in activating
and practicing trunk rotation. This trunk rotation was fol- the switches, noting the level of support and the position in
lowed by weight bearing on her hands while kneeling beside her chair that were optimal for achieving these activities. They
a bench. She moved from tall kneeling to trunk rotation in recommended that she continue to practice in the classroom.

Principles of Neurodevelopmental Therapy Used to movements in a quadruped position). Specialized handling of

Promote Hand Function children with cerebral palsy is believed to allow the develop-
Principles of the neurodevelopmental approach have evolved ment of new patterns of more normal movement and provide
since the Bobaths originated the intervention concepts. At the basis for ongoing motor skill development. Case Study 8-2
its inception and as practiced through the 1970s and 1980s, explains how the NDT approach can be applied to improve a
NDT involved extensive handling by a trained occupational child’s development of hand function.
therapist.66 More recently, NDT-trained occupational thera- Postural stability is important to hand function, and a child’s
pists have adopted motor learning principles and dynamic ability to control isolated movements of fingers, thumb, and
systems theories.66 Many of the principles have been integrated hand arches requires a stable base of support that allows these
into other practice models and approaches; for example, precise and coordinated movements. Stability of all proximal
Howle67 defines how the goals and principles of NDT and structures—the pelvis, trunk, shoulders, elbow, forearm, and
motor learning are integrated in current practice. Child goals wrist—allows these fine hand movements. Occupational thera-
include: pists facilitate postural tone through therapeutic handling at
• Postural alignment and postural tone that allows fluid tran- key points (most often, the shoulders and pelvis). By handling
sitional movements through a variety of positions in a play activity, the occupational therapist guides the child
• Improved foundational postural stability to support optimal through small weight shifts and movements in different planes
hand function that specifically activate or modulate postural tone. When a
Copyright © 2014. Elsevier. All rights reserved.

• Efficient weight shift and equilibrium responses in upright child learns to control weight shifts and equilibrium responses,
positions he or she may gain improved control of arm movement for
• Improved control of isolated and dissociated extremity reach and bimanual tasks. The occupational therapist primarily
movements facilitates rotational patterns of movement as the basis for
• Enhanced mobility and dynamic stability within and between normal movement patterns. For example, the occupational
body positions therapist can facilitate slow rotary movements in small ranges
Occupational therapists implement NDT techniques to of motion in shoulder rotation and forearm pronation and
inhibit spasticity and primitive reflexes and facilitate normal supination to inhibit the child’s arm tone before implementing
movement patterns. Specifically, the occupational therapist uses a fine motor activity.
sensory input such as deep pressure and upper extremity weight Weight bearing on hands during intervention activities is
bearing with the spine and body in good alignment. These particularly useful for improving postural control and improv-
techniques facilitate postural tone to increase dynamic stability, ing stability in the scapulohumeral area (Figure 8-11). The
that is, postural tone that supports movements through differ- occupational therapist can also use upper extremity weight
ent planes (e.g., lateral weight shifts when sitting or rotational bearing to encourage the child to maintain elbow co-contraction

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 CHAPTER  8  Hand Function Evaluation and Intervention 239

perform in an elbow flexed position, and the child can first

practice active supination in activities that position the elbow
in greater than 90 degrees of flexion (e.g., eating finger foods,
donning dress-up hats, and putting lotion on the face). Supina-
tion of 90 degrees or more is needed to accomplish functional
activities such as drinking, eating with utensils, or turning a
doorknob.
As noted above, manipulation is often optimal when the
child is positioned with good postural stability and support,
including support of shoulder stability and a working surface
that fully supports forearm and hand. The MCP joints (i.e., the
palmar arch) can be key points of control to promote isolated
fingers movements. The occupational therapist may offer
support of palm at the MCP joints as the child practices activi-
ties that specifically require isolated movements in a supportive
surface.125 Games that include grasping chips, marbles, small
FIGURE 8-11  Weight bearing on hands improves shoulder boxes, or pick-up sticks provide practice of isolated finger
and arm stability. It also promotes wrist extension and, for movement. The occupational therapist may handle the child
certain children, finger extension. during these activities by supporting the shoulder, guiding the
wrist into extension, supporting the palmar arch, or guiding
the forearm into supination.
Research of Neurodevelopmental Therapy Related
to Hand Function Interventions
Although understanding of cerebral palsy and diagnoses in
which muscle tone and function are impaired has increased
because of Bobath’s work and that of NDT-trained therapists,
the trials of NDT principles and handling techniques have not
demonstrated strong efficacy. NDT handling techniques by
occupational therapists were examined in two randomized trials
by Law and colleagues in the 1990s. Neither study found
support for NDT in improving the hand function of children
with cerebral palsy more than regular (usual care) intervention.
In the second trial the preschool children received more NDT
sessions than regular occupational therapy but did not differ in
hand function or quality of movement after the interventions.79
Both groups made significant gains in hand function. Three
FIGURE 8-12  Weight bearing on forearms or hands can
systematic reviews11,20,94 synthesized the research evidence for
be practiced using functional activities. This child maintains
NDT and concluded that NDT does not appear to result in
an upper extremity weight-bearing position on his affected
positive benefit and functional improvement in children with
arm while engaged in a computer tablet activity.
cerebral palsy. Of 15 studies, Novak found only three that
demonstrated benefit from NDT and concluded that the evi-
dence does not support NDT for improving contractures,
and wrist extension.10 Depending on the child’s skill level, the muscle tone, or functional outcomes. These studies suggest
occupational therapist can carry out weight-bearing activities that the specific handling techniques used in NDT may not
with the child in a prone position on forearms, a prone position result in significant improvement in motor function, and use
on extended arms, or a side-sitting position (Figure 8-12). of NDT techniques in occupational therapy should be carefully
Copyright © 2014. Elsevier. All rights reserved.

For the child who has tightness in wrist flexion, a position monitored and evaluated to determine if the child is benefitting
of upper extremity weight bearing on hands with the arms and making expected progress.
extended may be difficult, if not impossible, to achieve. The Despite lack of evidence, the principles introduced by the
most appropriate positions for children with wrist tightness to Bobaths have deepened therapists’ understanding of cerebral
use for weight bearing include prone on the forearms and side- palsy and disorders that include muscle tone impairments. As
lying. If the child’s thumb is tightly adducted and flexed, the explained by Howle,67 certain NDT practices translate to other
occupational therapist can apply firm pressure over the first practice models and have validity through clinical practices with
MCP joint and use slow, small, rotary movements to relax the children with cerebral palsy. Therapists recognize the impor-
child’s hand before this activity. tance of enhancing postural stability as the child’s base of
Important functional outcomes of NDT include improved support for control of hand function. The occupational thera-
control of isolated arm, hand, and finger movements required pist can provide activities and handling that inhibit stereotypic
in manipulation and bimanual activities.125 For example, often movement patterns or reduce joint stiffness. The goals that
children with cerebral palsy lack control of supination and were originally identified within the NDT practice model are
forearm muscles can be spastic. Active supination is easiest to often achieved in current practices through positioning and

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 240 SECTION  III Occupational Therapy Intervention: Performance Areas

seating, Botox or baclofen treatments, electrical stimulation, to follow a model or instructions, engage in repetitive practice,
practice opportunities, and motor learning techniques. and understand specific, descriptive reinforcement can benefit
More recently developed practice models are based on learn- from motor learning interventions. Although infants may
ing and behavioral theories. These models have emerging evi- have difficulty staying engaged and repeating action, most
dence of effectiveness and translate well into occupation-based preschoolers and older children are easily motivated to engage
interventions. Efficacious practice models, such as motor learn- in activities with high repetition and some challenge.
ing, that use occupation-based theories are described in the Application of motor learning approaches and principles has
following section. been examined in children with developmental coordination
disorder,90 children with cerebral palsy,73 and adults with brain
injury.87 Interventions that explicitly access learning principles
Occupation-Based Approaches appear to be effective in promoting hand function for children
Occupation-based approaches emphasize the interaction of with developmental coordination disorder.90 Mastos and col-
person, environment, and occupation and use holistic methods leagues87 studied the effects of goal-directed therapy using
to support the child’s skill development. Using this approach, motor learning principles on individuals post brain injury. The
an occupational therapist selects and creates activities that facili- two participants met their goals using task-oriented therapeutic
tate the child’s functional performance by considering (1) the practice that included whole tasks, repetition (intense practice),
child’s motivation and interests; (2) the context of perfor- and structured feedback. In a randomized controlled trial, chil-
mance, including activity demands, constraints, and natural dren with cerebral palsy, including those with hemiparesis,
supports; and (3) the child’s performance strengths and limita- diplegia, and quadriplegia, made gains in functional perfor-
tions. The interaction of child, environment, and occupation mance following 6 months of physical therapy using a func-
determines how well and at which developmental level the child tional program that included motor learning principles.73
participates in play, mobility, social relationships, and ADLs. Although this trial’s primary focus was on gross motor skills,
Interventions may focus on any or all of these variables, and in the children, most of whom had upper extremity impairments,
typical practice the focus shifts among them. Occupation-based improved in self-care, suggesting improvement in hand func-
models are congruent with dynamic systems theories (see tion. Using case reports, Eliasson36 explained how the complex-
Chapters 2 and 7) in understanding the multiple child-related ity of hand function in children with cerebral palsy warrants
and context-specific variables that influence performance. Key holistic approaches such as occupation-based and motor learn-
to these approaches is appreciation of meaningful and preferred ing models. These models incorporate the multiple variables
play occupations, particularly social play, as the context for that she identified influence hand function, that is, self-efficacy,
intervention and the context for much of the child’s learning attention, cognition, motivation, sensorimotor systems, per-
and development. Two practice models that reflect occupation- ception, and musculoskeletal/biomechanical structures. The
based approaches to improve children’s hand function are (1) case reports36,73 and small trials suggest that motor learning
motor learning and (2) pediatric-constraint induced movement models can have positive effects on hand function in children
therapy. Two other occupation-based models are frequently and youth with a variety of diagnoses.
used to promote children’s hand function: Cognitive Orienta- Motor Learning Principles and Techniques
tion to daily Occupational Performance (CO-OP) and occupa- Motor learning theories posit how children develop motor skills
tional therapy using sensory integration (OT-SI). CO-OP is in the course of daily activity132 and include both foundational
described in Chapter 10 and OT-SI is explained in Chapter 9; theories that explain how children learn movement and trans-
therefore these practice models and associated strategies are not formational principles that form the basis for intervention prin-
described in this chapter. ciples and strategies. For our purposes, foundational motor
learning theories are (1) schema theory, (2) dynamic systems
Motor Learning Practice Model theory, and (3) stages of learning. These basic concepts about
Motor learning is an occupation-based approach that helps the motor development and learning provide a context for design-
child achieve motor goals using problem solving, practice with ing interventions and are briefly described below. They are
reinforcement, whole task activities, and refinement of skill in further explained in this chapter and in Chapter 2. Schema
everyday activities.18 Using motor learning principles, the occu- theory defines how a child learns movement patterns by build-
pational therapist assists the child in acquiring motor skills ing new movements on established motor patterns.116,132 To
Copyright © 2014. Elsevier. All rights reserved.

through structured activities, practice of targeted skills, and improve efficiency of learning and to allow automatic move-
specific types of feedback. The occupational therapist selects ments, humans use similar movement patterns repeatedly, albeit
the type of practice and feedback based on the child’s level of with variation and flexibility, to accomplish everyday tasks. For
performance and response to intervention. Using the child’s example, similar movement patterns are used to brush teeth,
interest to guide activity selection, the child is engaged in comb hair, and wash the face. Dynamic systems theory and
meaningful whole tasks that have embedded targeted move- occupation-based theories recognize how multiple variables in
ment patterns. Through practice of these activities with rein- the child, the activity, and the environment influence perfor-
forcement that specifically guides the child’s learning, the child mance. When interventions use motor learning theories, con-
masters new skills. straints and resources of environment, activity demands, and
Types of Children Who Benefit from Motor child strengths and limitations are considered and purposely
Learning Approaches manipulated to promote new learning and skill development.
Because motor learning approaches are based on general learn- The child’s stage of learning (i.e., cognitive, associative, or
ing theories, many types of children can participate in and automatic) also provides a foundation for selecting an appropri-
benefit from this practice model. Children who have aptitude ate intervention activity and planning how to elicit and support

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 CHAPTER  8  Hand Function Evaluation and Intervention 241

TABLE 8-7 Principles and Examples of Motor Learning Theory

Principle Application

Learning a whole motor task is more effective Whole motor tasks can provide the child with a meaningful goal, sustain his
and motivating than learning part of a or her attention, and become the context for repetition.
movement.
A meaningful, preferred activity is selected. When a preferred activity is selected, the child is more likely to remain
engaged.61
Frequent, repetitive practice is required to learn Children must practice motor actions repeatedly to reach the automatic stage
new motor skills. of learning. Generally, the number of repetitions required is
underestimated. For example, children take thousands of steps with
supports before they achieve independent ambulation3 (Adolf, Vereijken,
& Shrout, 2003). Practice is equally important for learning hand functions.
Practice should include variability and should be Children retain more when motor practice is varied within the context of the
distributed across time activity. This generally happens naturally when building a structure,
playing a game, or performing ADLs.
The occupational therapist provides structured Specific feedback reinforcement learning by increasing the child’s
reinforcement that includes specific feedback understanding of his or her performance. “You reached higher that time!”
about performance. “You made a perfect letter B.”
Feedback or reinforcement is provided Children appear to perform best when they receive consistent
frequently and consistently. reinforcement.122
Specific activities are structured to support Learning of specific motor skills in a therapy session may not generalize to
transfer of learning to a variety of natural natural environment and varied contexts. Therapists encourage practice of
environments. new skills in a variety of environments with supports as needed. Caregivers
and teachers reinforce the child attempting new motor skills in a variety
of environments.

practice of the child’s highest level skills. Understanding these and wanted to build an entire track to show his father. Building
stages helps the occupational therapist identify the next step in the track required 22 repetitions of placing pieces together,
the child’s learning and select appropriate challenges and sup- naturally requiring repetition. Therefore this activity exempli-
ports for each stage.18,52 In the cognitive stage of learning the fies a good choice using motor learning principles. Case Study
child is highly attentive to the activity, learning how to approach 8-3 illustrates use of motor learning principles with a child with
it, often using trial-and-error to develop a strategy for accom- cerebral palsy.
plishing the activity goal (e.g., creating a bridge out of Legos). Repetition and practice are important to establishing and
In the associative stage of learning, movements are less variable retaining new motor skills and hand functions.36 Therefore,
and the child refines the movements that accomplish the goal. eating activities and toys and games with many pieces can be
In the automatic stage, the child practices his or her skills with particularly useful and enjoyable for developing precision grasp-
less cognitive effort and less attention required. Performance ing skills (Figures 8-14). Eating is often motivating and if
that is automatic (e.g., putting on a coat, opening a jar) allows designed to provide the just-right challenge, for example, using
people to perform efficiently and attend to meaningful goals. a spoon with a new food (such as blueberries) that is challeng-
The stages of learning also suggest that learning processes ing to scoop, the child will engage in the challenging activity
extend over time, requiring repeated practice in varied repeatedly. The occupational therapist reinforces the child’s
environments. actions and praises how she is holding the spoon and scooping
The transformation principles used to design motor learning blueberries onto the spoon.
interventions are listed in Table 8-7 with examples. These Although children with cerebral palsy can acquire new hand
principles define how to select intervention activities, structure function, including more precise grasp and release, they require
Copyright © 2014. Elsevier. All rights reserved.

practice and reinforcement, and help the child generalize new more practice than do typically developing children.57 Research
motor skills. To apply motor learning principles to occupational has demonstrated that as children with cerebral palsy learn new
therapy intervention, first the occupational therapist selects a skills, each stage of learning (i.e., cognitive, associative, and
meaningful goal-directed activity that is preferred by the child. automatic) takes longer and requires more practice than these
The activity selected allows practice of movements that are learning stages require for typical children.36,37
missing, delayed, or difficult for the child and a just-right chal- For children with autism spectrum disorder (ASD) or DCD,
lenge for his or her emerging hand functions. For example, a hand function goals may include managing fasteners to dress
therapist may select building a train track with a 4-year-old independently each morning or legible handwriting for school
child who has unilateral cerebral palsy. Fitting together train assignments. Because children with ASD or DCD often strug-
track pieces requires two hands working together with preci- gle with higher level hand function, such as in-hand manipula-
sion grasp, stable wrists, and forearm supination. Pressing the tion and bimanual coordination, one component emphasized
train track pieces together using weight bearing on hands in designing intervention activities are tasks that facilitate
requires shoulder strength and bimanual coordination (Figure in-hand manipulation skills. Box 8-3 lists examples of specific
8-13). The child selected this activity because he loves trains activities that can be incorporated in games, ADLs, and play to

Case-Smith, J., & O'Brien, J. C. (2014). Occupational therapy for children and adolescents. Retrieved from http://ebookcentral.proquest.com
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 242 SECTION  III Occupational Therapy Intervention: Performance Areas

FIGURE 8-13  This child with unilateral cerebral palsy puts together the train cars and
places them on the track. This activity inherently has repetition and requires bimanual skill.

CASE STUDY 8-3 Use of Motor Learning Principles to Improve Hand Function
Simon: Use of Motor Learning Principles with Legos and giving frequent reinforcement and encourage-
Child with Hemiparesis ment. As the tower became taller, Simon did not have a
Simon was 4 years old and had right hemiparesis cerebral palsy supporting surface and was challenged to hold both arms in
following preterm birth and a grade III intraventricular hem- space. The occupational therapist suggested ways to place the
orrhage. He was bright and cooperative, although he strug- Legos to make the task easier when he observed that Simon
gled to use his right hand and typically performed activities was fatiguing and to make the task more challenging when
using only his left hand. Simon’s father was an airplane pilot, he wanted to push Simon to the next skill level.
and Simon loves airplanes and airports. The 30-minute activity was fatiguing but Simon remained
Simon’s occupational therapist provided services in the engaged because the occupational therapist was encouraging
home. In this session Simon and the occupational therapist and airports were a favorite activity. He knew that when
decided to build an air control tower that included a garage the air control tower was completed, he could play with
for airplanes to trolley through and park for repairs. They used his airplane, driving through the port at the base and flying
medium-sized Legos that required firm fingertip grasp with by it.
stable wrist and arm to fit the pieces together. The occupa- When the air control tower was completed, the occupa-
Copyright © 2014. Elsevier. All rights reserved.

tional therapist assisted Simon intermittently in fitting pieces tional therapist discussed with Simon’s father how to use
together and allowed him to sometimes press them together Lego activities to encourage bimanual hand skills. The father
using one hand with the Lego stabilized on the floor surface. planned to build another tower with Simon that weekend, to
The tower required that 40 Legos be pressed together; it continue his practice and to generalize his skills to play with
required 30 minutes to complete the tower with the occupa- partners who would offer different levels and types of rein-
tional therapist providing some assistance with stabilizing the forcement. See Figure 8-11.

promote in-hand manipulation. The occupational therapist can to promote success and how to motivate the child to practice
guide and support repeated practice of dressing skills in pretend the tasks (e.g., fastening) that are most difficult.
dress-up play, doll dress-up, or morning dressing. Because Handwriting is also a frequent goal for children with ASD
dressing most often occurs with caregivers, the occupational or DCD. Denton et al.34 found that intensive handwriting
therapist recommends to parents how to arrange dressing tasks practice was more effective in promoting handwriting legibility

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 CHAPTER  8  Hand Function Evaluation and Intervention 243

FIGURE 8-14  This child completes a two-hand activity of cutting play fruit with a plastic
knife. The occupational therapist suggests which hand should hold the knife and helps him
position the knife and fruit for success. Associated movements suggest that the task is a
challenge for this boy.

than practice of sensorimotor performance components. Case- patterns and in-hand manipulation skills for children with
Smith et al.19 also used motor learning principles to enhance developmental coordination disorder or mild delays in hand
handwriting legibility in first grade students. They incorporated function.
handwriting practice into meaningful activities (e.g., small Motor Learning Research
group activities with playful, social elements) and encouraged Motor learning interventions have been researched in adults86;
peer supports. The occupational therapist and teacher team however, few studies of motor learning interventions for chil-
structured handwriting practice, provided immediate reinforce- dren have been published. In a descriptive study, Eliasson36
ment, solicited peer feedback, and guided transfer of handwrit- explains how to design interventions that incorporate motor
ing skills to writing tasks. These learning strategies resulted in learning principles, using examples of tasks for children with
significant improvement in handwriting legibility when com- cerebral palsy. Using case reports, she explains how to structure
pared with traditional handwriting instruction.19 meaningful, child-selected tasks, elicit distributed practice, and
Copyright © 2014. Elsevier. All rights reserved.

For children with mild delays in hand function who have provide reinforcement. Each case demonstrated qualitative
limited in-hand manipulation, games and crafts with small improvement in hand function.
objects and dynamic use of tools (e.g., scissors) can be used to Several group comparative studies of motor learning prin-
practice, reinforce, and gain control of isolated finger move- ciples have been completed. In a study of “neuromotor task
ments. The occupational therapist selects manipulative tasks training” in which motor learning principles were applied to
that require practice of dissociated movements, translation children with DCD, therapists were trained to teach children
of small game pieces in and out of the hand, and rotation whole motor tasks by giving explicit instruction, sharing spe-
of small objects within the hand.44 Games with marbles, cific information about the child’s performance, and providing
pick-up sticks, or chips require that children practice and feedback when the task was completed.93 The children who
repeat in-hand manipulation. Children often experience more received this intervention improved more in motor coordina-
success when their hand is stabilized on a surface. As skills tion and gross motor function than children who received no
progress they should be encouraged to manipulate objects intervention. In a second study of children with DCD who
without the forearm and wrist supported. Table 8-8 lists games received a task-oriented treatment program using motor
and activities that can be practiced to develop dynamic grasping learning principles, the intervention group improved more in

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 244 SECTION  III Occupational Therapy Intervention: Performance Areas

BOX 8-3 In-Hand Manipulation Activities That Can Be Embedded When Using Motor
Learning Principles

Preparation Activities • Moving small food items into the mouth

1. Activities involving general tactile awareness (easily re- • Holding several chips to put on a wand
peated, generally not a skill challenge) • Handling money to put it into a coin bank
• Using Crazy Foam 3. Shift
• Using shaving cream • Turning pages in a book
• Applying hand lotion • Picking up sheets of paper, tissue paper, or dollar bills
• Finger painting • Separating playing cards
2. Activities involving proprioceptive input (increases cocon- • Stringing beads (shifting string and bead as string goes
traction, strength, endurance; easily repeated) through the bead)
• Weight bearing (e.g., wheelbarrow, activities on a small • Shifting a crayon, pencil, or pen for coloring or writing
ball) • Shifting paper in the nonpreferred hand while cutting
• Pushing heavy objects (e.g., boxes, chairs, benches) • Playing with Tinker Toys (long, thin pieces) or pick-up
• Pulling (e.g., tug-of-war) sticks
• Pressing different parts of the hand into clay • Adjusting a spoon, fork, or knife for appropriate use
• Pushing fingers into clay or therapy putty • Holding a pen and pushing the cap off with the same
• Pushing shapes out of perforated cardboard hand
• Tearing open packages or boxes • Holding chips while flipping one out of the fingers
3. Activities involving regulation of pressure • Holding fabric in the hand while attempting to button
• Rolling clay into a ball or snap
• Squeezing water out of a sponge or washcloth 4. Simple or complex rotation (depending on object
• Pushing snaps together orientation)
4. Activities involving tactile discrimination • Removing or putting on a small jar lid
• Playing finger games and singing songs • Putting on or removing bolts from nuts
• Playing finger identification games • Rotating a crayon or pencil
• Discriminating among objects or textures by manipulat- • Removing crayons from the box and preparing for
ing with vision occluded coloring
• Rotating a pen or marker to put the top on it
Specific In-Hand Manipulation Activities • Rotating toy people to put them in chairs, a bus, or a
1. Translation (fingers to palm) boat
• Prehending coins from a container • Rotating a puzzle piece for placement in the puzzle
• Hiding pennies in the hand (magic trick) • Feeling objects or shapes to identify them
• Crumpling paper • Handling construction toy pieces
• Picking up small pieces of food • Turning cubes that have pictures on all six sides
• Taking chips attached to a magnetic wand • Constructing twisted shapes with pipe cleaners
• Picking up pegs or paper clips for use in a game or craft • Handling parts of a small-shape container while rotating
• Picking up several utensils one at a time the shape to put it into the container
2. Translation (palm to fingers) • Holding a key ring with keys, rotating the correct one
• Moving pennies from the palm to the fingers for placement in a lock
• Moving game pieces to place onto a game board

TABLE 8-8 Examples of Activities That Promote Hand Function in Children 3 to 8 Years Old
Activity Child Goal Specific Hand Functions Targeted

Basket weaving Make a basket for mother; share yarn colors In-hand manipulation simple rotation as child
Copyright © 2014. Elsevier. All rights reserved.

Repetition of pulling yarns with friends moves basket while pulling through yarn
through basket frame
Sponge painting Create colorful painting using small sponges, Precision grasp of sponge, carry of sponge;
making favorite animals translation when prehending sponge
Nuts and bolts Make box with nuts and bolts around top; Rotation and translation
make design with nuts and bolts
Eye dropper painting Make multicolor painting for parents or for Precision grasp, precision release
holiday
Cleaning the white board Helping the teacher with classroom cleanup Isolated finger strength and coordination to
with water spray operate spray bottle
Perfection game Play with peers; social elements promote Translation to move piece in and out of hand;
motivation and effort precision placement; precision release, repetition
Tissue paper mural Create a mural for classroom with peers, Precision grasp; hand strength, bimanual hand skills
tearing small pieces of tissue paper and
pasting to a large piece of paper

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 CHAPTER  8  Hand Function Evaluation and Intervention 245

handwriting, dexterity, and ball skills performance when com- early on in development the child learns adapted techniques for
pared with a control group.118 accomplishing his goals by using only the skillful or unaffected
In a study of typical children, Sullivan, Kantak, and Burtner122 arm and hand. Intervention such as P-CIMT that can promote
provided different frequencies of feedback as children learned and help integrate bimanual skills during infancy may prevent
a task involving arm movements. Compared with adults who this pattern of disregard.
perform optimally with intermittent feedback, the children P-CIMT has been used with children with a wide range of
performed optimally with continuous feedback and required impairment (i.e., severe to moderate) with equivalent benefit
longer periods of practice. This emerging but promising across level of involvement. Citing one exception, DeLuca
research evidence supports the use of motor learning principles et al.30 found that children with dystonia did not improve with
to improve hand function in children with a variety of P-CIMT and suggested that children with dystonia may
diagnoses.132 not benefit from P-CIMT. Because a child with dystonia has
very poor control of extremity movement with fluctuating
Pediatric Constraint-Induced Movement Therapy tone, gains with intervention may be limited, and such a child
Pediatric constraint-induced movement therapy (P-CIMT) may benefit most from adapted techniques and assistive
is a well-researched, widely used intervention for children technology.
with hemiparesis cerebral palsy (i.e., unilateral cerebral palsy). In recent examples, occupational therapists have imple-
P-CIMT evolved from constraint-induced movement therapy mented P-CIMT with children recovering from brachial plexus
for adults post stroke, which was originally developed and injuries. In two case reports, P-CIMT was applied to children
researched in the 1980s.95,130 Research applying CIMT to with Erb-Duchenne palsy (brachial plexus injury with impair-
young children with cerebral palsy emerged after 2000 with ment to spinal nerves C5 and C6 resulting in paralysis of
studies in New York, Alabama, and Sweden.22,29,42 Currently shoulder muscles, elbow flexors, and forearm supinators).115,124
many variations of P-CIMT have been studied, and virtually all In Santamato et al.115 the children (age 6 and 7 years) had
studies have produced positive effects on hand function in contractures and were treated with botulinum toxin injections
children with unilateral cerebral palsy. The core elements of before the P-CIMT program. Both studies reported significant
P-CIMT are (1) constraint of the child’s less impaired upper improvement in arm movement and hand function with
extremity, (2) selection of activities and techniques to elicit P-CIMT, suggesting potential benefit for children with bra-
specific movements of the more impaired arm and hand, (3) chial plexus injuries.106
high intensity intervention with repetition of targeted move- P-CIMT Principles and Strategies
ments, (4) sessions in the child’s natural environment (note: As noted, a feature of P-CIMT is use of constraint of the child’s
sessions are sometimes held in clinics, hospitals, or schools), less affected or unaffected upper extremity. Researchers and
(5) systematic reinforcement that directs the child to attempt practitioners have used different types of constraints, including
higher level skills or demonstrate increased strength and endur- mitts,22 splints inserted into gloves, slings,1 and full arm casts.19
ance, and (6) transfer of the intervention program to caregivers Although the effects of constraints cannot be compared across
and the child’s daily routines. Although constraint is an essen- studies, the principles supporting type of constraint are dis-
tial part of P-CIMT, virtually all programs include sessions tinctly different. When splints and mitts are used, the child
without constraint (most often in the final weeks or days of the wears these forms of constraint only during the intervention
intervention) that emphasize integration of bimanual skills. sessions. In P-CIMT using full-arm casts, the child wears the
The variations of these essential components are explained in cast continually (i.e., full time), “forcing” him or her to primar-
the following sections. ily use the affected arm and hand throughout the day and
Types of Children Who Benefit from P-CIMT beyond the intervention session (Figure 8-15).
P-CIMT was originally developed for children with hemiparetic
cerebral palsy and hemiparesis caused by acquired brain injury.72
Research findings suggest that P-CIMT is successful with chil-
dren across age groups (15 months to 20 years).66,103 Eliasson
et al. found that older children improved more with P-CIMT
than younger, but this finding has been inconsistent across
studies, with most showing no difference in improvement
Copyright © 2014. Elsevier. All rights reserved.

based on age. Recent studies have shown benefits for infants

with unilateral cerebral palsy.83 Although practitioners recog-
nize that neuroplasticity is greatest in infancy, certain scholars
are concerned about use of constraint at early stages of biman-
ual development; therefore, careful monitoring for potential
negative effects is warranted when applying P-CIMT to infants
less than 12 months.
One rationale for using P-CIMT with infants is the potential
to prevent the phenomenon of “developmental disregard.”
Developmental disregard refers to a pattern observed in chil-
dren with congenital hemiparesis in which they neglect their
affected arm and hand.31,103 This pattern seems to evolve from
repeated experiences when the child attempts to use the hemi- FIGURE 8-15  In P-CIMT often a full arm cast is used as the
paretic hand and fails to achieve his or her goal. Therefore, constraint. The child wears a typical CIMT full-arm cast.

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 246 SECTION  III Occupational Therapy Intervention: Performance Areas

TABLE 8-9 Pediatric Constraint-Induced Movement Therapy (P-CIMT) Principles

and Strategies
Principle Explanation and Examples

Intervention takes place in the child’s natural The child’s home is a comfortable environment for intensive practice of skills,
environment. allows selection of meaningful and preferred activities, and allows easy
engagement of the caregiver in the intervention sessions.
The child’s less-affected arm and hand are Constraints include mitts, splints, slings, gloves, or casts. A full-arm cast limits
constrained. sensorimotor input to the less affected arm, potentially inhibiting brain
activity in the nonimpaired hemisphere.
The occupational therapist guides intensive The occupational therapist encourages the child to repeat specific, targeted
practice or targeted movements in whole movement patterns in meaningful (fun) play activities and family-selected
tasks. self-care activities.
The occupational therapist encourages the Using a process termed “shaping,” the occupational therapist encourages the
child to master emerging skills or the child to attempt challenging skills, reinforces the child’s efforts, reinforces
just-right challenge. repetition, monitors performance, and guides activity to refine movement
patterns.
The occupational therapist uses reinforcement The occupational therapist uses immediate reinforcement (i.e., praise) that
that is specific and positive and supports encourages sustained performance, guides higher level performance, and
the child’s learning about performance. results in skills refinement.
The occupational therapist collaborates with The occupational therapist establishes goals with the caregiver at the initiation
the parents in establishing goals, assessing of the P-CIMT program. The goals are assessed and monitored routinely
and monitoring the child’s progress. (e.g., each week). Formal communication methods are established to
communicate the child’s performance during therapy sessions and at home
after therapy sessions.
The occupational therapist transfers the At the conclusion of the P-CIMT session, the occupational therapist develops a
intervention program to the caregiver. home program that extends the original goals and suggests activities that
encourage the child’s practice of bimanual skills and the next developmental
steps.

Emerging evidence suggests that by inhibiting sensorimotor principles that guide intervention with example strategies are
functions of the less affected arm and hand for an extended presented in Table 8-9. After analysis of the missing or impaired
period (e.g., 3 weeks), the brain may reorganize. A neuroimag- components of arm and hand movements, the occupational
ing study found that inhibiting the unaffected hemisphere was therapist designs play and social activities that elicit and provide
associated with activation in the impaired hemisphere.123 The a context for practice of specific hand functions. With sessions
slowing of neural input to the unimpaired hemisphere may of 2 to 3 hours, the occupational therapist can select meaning-
allow the development of new pathways within the impaired ful activities that may require many steps to complete (e.g.,
hemisphere.18 Although emerging evidence from imaging making muffins, building a castle of Legos, a morning dressing
studies suggests benefit123 and the full-time full arm cast results and bathing routine). The child repeats targeted movements
in more practice with the affected arm and hand, it may reduce within the play or self-care activity that are reinforced by the
opportunities for bimanual integration during the intervention occupational therapist’s praise, descriptive feedback, and
period. Some researchers believe that intensive, highly struc- encouragement. The occupational therapist prompts and cues
tured bimanual interventions in which the child is not con- the child to attempt movements that are higher level (e.g., to
strained better align with the goal of increasing bimanual reach higher, supinate more, grasp multiple pieces). Using
function. Intensive bimanual interventions,61 when provided continual activity analysis, the occupational therapist judges
with high structure, appear to be as effective as P-CIMT.62 when the child needs supports or encouragement and when
Copyright © 2014. Elsevier. All rights reserved.

Most often P-CIMT is provided in an intensive (3-6 hour) the child can be further challenged. The intervention sessions
daily program of 2 to 4 weeks.103 Short-term, intensive occu- provide continuous cycles of (1) selecting an activity that pres-
pational therapy services allow the child and family to focus on ents a motor challenge (elicits the targeted movement), (2)
specific functional goals, engage in daily goal-directed practice, observing the child’s performance, (3) reinforcing the child’s
and assess intervention outcomes. Pediatric hospitals and clinics performance, (4) encouraging the child to repeat the action,
across the United States are implementing short-term intensive and (5) monitoring how the child refines the movement
occupational and physical therapy services as a service delivery pattern.30 For example, during the bimanual intervention phase
model that may be more effective, more accountable, and more the occupational therapist designs a folding, cutting, and
family-friendly than continuous (year round) weekly therapy pasting activity that includes easy shapes and more difficult
services. Short-term, intensive P-CIMT has resulted in signifi- shapes to cut with scissors. The occupational therapist initially
cantly improved hand function and bimanual hand use with helps the child stabilize the paper, then encourages the child
sustained outcomes at follow-up.19 to stabilize it. The child is positioned at a table for the activity;
The occupational therapist incorporates both motor learn- however, the occupational therapist encourages the child to cut
ing and shaping techniques in the P-CIMT sessions. These without using the table as a support, facilitates movement of

Case-Smith, J., & O'Brien, J. C. (2014). Occupational therapy for children and adolescents. Retrieved from http://ebookcentral.proquest.com
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 CHAPTER  8  Hand Function Evaluation and Intervention 247

FIGURE 8-16  Bear crawling on carpet allows more weight

bearing on hands than does the quadruped position. The
occupational therapist demonstrates and joins in the race.

the affected arm into different planes, and encourages active

supination. The occupational therapist increases or fades out
supports depending on the complexity and challenges inherent
in each cutting and folding task.
For young children, scooping and eating with a spoon can
be challenging and is naturally repetitive. Eating can be a moti-
vating activity with multiple steps that the occupational thera-
pist can grade to challenge the child’s current skill level.
Crawling through the living room over carpet and pillows
elicits wrist extension, open hand (finger extension), and shoul-
der external rotation (Figure 8-16). Sustained crawling requires
upper extremity stability and strength. The carpet texture may
be beneficial to children whose hands are hypersensitive to
touch. Crawling games can include siblings, can be extended
by playing hide and seek, can provide a break from intensive
practice of grasp in fine motor activities, and are appropriate
across age groups.
Although P-CIMT is provided in clinics and outpatient
hospital settings, Ramey et al.103 recommend that therapists
provide the sessions in the child’s home and other natural
environments. Services in the home with parents present during
some or most of the sessions promote easier transfer of learn-
ing. Using the child’s own toys and objects ensures that he or
she can continue to practice new skills after the intervention
session. The occupational therapist can model techniques that
elicit the child’s highest level skills (Figure 8-17). Parent educa-
tion is an essential element of P-CIMT. Parent education is
Copyright © 2014. Elsevier. All rights reserved.

most likely to result in behavioral change when (1) the occu-

pational therapist first develops a positive relationship with the
family; (2) the parents’ learning styles and motivation are con-
sidered; (3) the family’s routine and time demands are consid- FIGURE 8-17  This child demonstrates his emerging
ered; and (4) the occupational therapist is responsive and strength and highest level skill using two hands to lift his
sensitive to the family’s needs and priorities. When services are Lego construction.
provided in the home, the occupational therapist can model for
the parent, interact on a regular basis, discuss the child’s prog-
ress, and provide education about the intervention according suggesting that this intervention has been broadly adopted.
the pace that is most comfortable for the parent. Case Study Although almost all studies have shown that P-CIMT has posi-
8-4 describes P-CIMT for a child with unilateral cerebral palsy. tive effects on hand function for children with unilateral cere-
P-CIMT Research bral palsy, the studies have been criticized for lack of follow-up
Since 2000, more than 50 studies of P-CIMT have been pub- measures and differences in intensity between the intervention
lished. Research has been completed in more than 10 countries, and control groups that may account for differences in

Case-Smith, J., & O'Brien, J. C. (2014). Occupational therapy for children and adolescents. Retrieved from http://ebookcentral.proquest.com
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 248 SECTION  III Occupational Therapy Intervention: Performance Areas

CASE STUDY 8-4 P-CIMT for a Child with Unilateral Hemiparesis

P-CIMT Camp theme of their intervention program was “Pirates,” and it
Many hospitals and clinics offer P-CIMT during the summer took place in the Netherlands. The children attended the
using a camp model with groups of children with hemiparesis camp for 3-hour sessions, 3 days per week, and daily activities
cerebral palsy participating. Examples of camps are those with included the following:
specific themes, such as a rock ‘n’ roll P-CIMT camp or one • As a group they dressed in pirate costumes that included
that is held outdoors and includes many adapted outdoor a sling for their less affected arm (during the constraint
activities (e.g., scavenger hunts, boating, animal exploration, weeks).
obstacle courses). • They practiced targeted movement with a plastic sword
Camps offer many positive social elements, making it easy while singing pirate songs.
to create fun activities while promoting shaping and repetitive • Each then had an individualized session to target specific
practice. Once an age range is selected, the types of activities tasks.
can be selected. Most camps offer all-day activities that include • As a group they participated in eating and drinking, rein-
eating, social activities, fun yet challenging activities, and forcing use of their more affected arm and hand.
housekeeping activities. For example, using a rock ‘n’ roll • In small groups they participated in board games, card
theme with children 8 to 12 years, the camp provides dancing, games, puzzles, and arts and crafts according to their
singing, playing musical instruments, making collages of rock developmental level and targeted goals.
‘n’ roll images, and performing for families. These fun activi- • At the conclusion they changed into their own clothes to
ties are scheduled before and after preparing and eating lunch prepare to go home.
with cleanup. The pirate group intervention resulted in significant
A preschool camp may include a Disney theme with positive effects on individualized goals as measured by Goal
pretend play activities focused on Disney characters, singing Attainment Scaling and standardized measures (the Assisting
and dancing, Disney arts and crafts, and gross motor play. Hand Assessment and the ABILHAND-Kids).
Aarts, Jongerius, Geerdink, Limbeek, and Geurts1 Aarts et al. concluded that “the Pirate group provided a
described a group intervention for children with unilateral meaningful and challenging environment for the children,
cerebral palsy (ages 2.5-8 years) that included 6 weeks of who enjoyed the playlike treatment and the provocative activi-
constraint and 2 weeks of bimanual task-specific training. The ties with peers.”

outcomes. As noted earlier, researchers have used widely varied that a program of 3 hours per day may yield as many benefits
forms of constraint (mitt, sling, splint, cast) and different inten- to a child’s hand function as a program of 6 hours per day.
sities (2-6 hours/day over 2 to 4 weeks). Because studies have A recent large randomized trial completed in Italy45 com-
used different measures and study samples have different char- pared three groups of children with hemiplegic cerebral palsy
acteristics, comparison of these important variables across (N = 105): P-CIMT, bimanual training, and standard treat-
studies is not possible.100 ment. The children in the P-CIMT group wore a glove with a
Four systematic reviews that included P-CIMT have been splint 3 hours per day for 10 weeks. The P-CIMT and bimanual
published since 2007.18,66-68,114 Each review included three ran- interventions were provided in a clinic, 3 days per week for 3
domized controlled trials and concluded that although most hours a day over 10 weeks, and the parents were instructed to
studies reported positive evidence, the trials remained small provide 3 hours per day on the other 4 days. Standard treat-
and differences in procedures prevented comparability across ment occurred once or twice a week. The two intensive inter-
studies. Among the recent studies, Aarts et al.1 examined the ventions resulted in significant effects on isolated arm and hand
effects of a group intervention that combined constraint and movements, grasp, and bilateral manipulation. ADLs improved
bimanual interventions with usual care. The children in the for the younger (2- to 6-year-old) but not older (7- to 8-year-
CIMT/bimanual groups demonstrated improved function in old) children. With positive results for most P-CIMT studies,
Copyright © 2014. Elsevier. All rights reserved.

the affected hand (including improved effectiveness as an assist- occupational therapists should prioritize translation of this
ing hand and increased bimanual performance during self-care intervention to clinic and program. Although major pediatric
and leisure activities) but did not improve in strength and auto- hospitals and some clinics provide CIMT using intensive sched-
maticity.2 In a randomized controlled trial reported by DeLuca ules, modified intervention models that obtain similar results
et al.30 and Case-Smith et al.,19 the effects of 3 hours per day are needed. Further study of P-CIMT models, including those
P-CIMT was compared with 6 hours per day P-CIMT for a that vary by types of constraint, dosage, individual or group,
sample of preschool children. This team used continuous full- and types of children who benefit, is needed.
arm casting, home-based services, and shaping/motor learning A barrier to broad use of CIMT is the intensive therapy
principles in the intervention sessions. The children who schedule that translates into commitment of therapist resources
received P-CIMT 3 hours per day, when compared with those and family time. Clinics have begun to provide group P-CIMT
who received 6 hours per day, made comparable improvements to maximize therapist resources.38 Home-based models are
in affected hand function and bimanual hand skills at 1 and 6 family-friendly models; however, they are most costly for
months post intervention. Effect sizes on hand function mea- therapy resources. With positive outcomes, expansion of
sures for both groups were large. This small study concluded P-CIMT is anticipated.

Case-Smith, J., & O'Brien, J. C. (2014). Occupational therapy for children and adolescents. Retrieved from http://ebookcentral.proquest.com
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 CHAPTER  8  Hand Function Evaluation and Intervention 249

function beginning at birth with limited increase in function

Adaptation Models over the course of development. Arthrogryposis multiplex con-
In many cases, children with neuromotor or musculoskeletal genital is characterized by abnormal fibrosis of muscle tissue,
disorders experience hand function impairments that remain causing contracture of upper and lower extremity joints.63
limiting despite interventions focused on remediation. Chil- Often the child’s elbow is locked in extension with forearm
dren with congenital orthopedic disorders (e.g., arthrogrypo- pronated, creating difficulty in eating and activities that require
sis), trauma resulting in permanent hand impairments (e.g., bringing hands to face. Because children with arthrogryposis
spinal cord injury or amputation), or severe neuromotor disor- experience limited ROM from birth, they often learn adapted
ders (e.g., spastic quadriparesis cerebral palsy), may benefit methods for accomplishing their goals and tend to be good
from adapted techniques or assistive technology to increase problem solvers.
their participation in hand function activities. Adaptation Congenital limb deficiencies can also affect hand function.
models reflect ecologic practice models in which contextual Conditions such as polydactyly (more than 5 fingers [including
features of the environment and activity are modified to increase an extra finger with bone but no joints]), syndactyly (webbed
the child’s participation in play, school functions, social interac- or fused fingers) or amelia (missing fingers or limbs) can result
tion, and ADLs. When a child has impaired hand function of in participation limitations for activities involving hand and
anticipated long duration, occupational therapists recommend, finger function. Children with congenital anomalies such as
select, and implement adapted techniques, adapted equipment, polydactyly or syndactyly generally undergo reconstructive
and assistive technology to improve the child’s participation in surgeries to increase hand function (see Chapter 29). Depend-
everyday activities. ing on the extent of involvement and success of the surgery,
To select appropriate adapted equipment or assistive tech- these children may benefit from adapted techniques and equip-
nology, the occupational therapist analyzes the child’s perfor- ment. Often children who are missing hands or parts of
mance and the activity demands and, using this information, the hand learn to perform ADLs and school activities with
identifies potential devices or technology that can compensate other body parts, rather than learn to use prostheses. When a
for the gap between the child’s performance and activity child determines that use of other body parts is more efficient
demands. Application of assistive technology to support a than use of a prosthesis, these adapted methods need to be
child’s hand function and participation also includes the occu- respected.
pational therapist’s involvement in purchasing, fitting, problem When a child or youth experiences a spinal cord injury that
solving or troubleshooting, adjusting, and training to success- results in quadriparesis, hand function can be permanently
fully use equipment or technology. Following analysis of impaired. When high-level injuries resulting in minimal arm
performance and desired activities, the occupational therapist and hand movement (e.g., at cervical vertebrae C3 or C4)
identifies available technology and assesses its potential useful- occur, children benefit from assistive technologies such a joy
ness, fit to the environment, cost, durability, and usability for sticks, switches, or mobile arm supports. When the spinal cord
a particular child’s hand function limitations and routine activ- injury is lower and the child retains wrist movement and partial
ity demands. Once the family (or school), based on the occu- hand function (e.g., at C6 or C7), adapted equipment, such as
pational therapist’s recommendations, decides to purchase a universal cuffs, built up handles, or handles on cups, allows
specialized device, the occupational therapist adjusts or fits the independence in specific ADLs. Children and youth with spinal
device; explains how it is used; models and instructs the child cord injury with quadriplegia can benefit from both low tech-
in how to use it; trains the family, teachers or other caregivers; nology, such as adapted spoons and writing utensils, and high
and assesses its functionality. These roles in selecting, training, technology, such as computer tablets, adapted computers, and
and assessment may be minimal or extensive depending on electronic aids for daily living.
whether the technology is simple or complex (see Chapter 20). Children with quadriparesis spastic cerebral palsy whose
This section describes the adaptation practice model, including movement is restricted or poorly controlled may benefit from
use of adapted equipment and assistive technology, to support use of assistive technologies such as switches and electronic
and improve hand function. devices. When severe muscle tone and muscle weakness limit
range of reach and motor control is minimal, adapted equip-
Types of Children Who Benefit from ment and technology become important to the child’s partici-
Activity Adaptation pation in play and ADLs. Children with severe athetoid
Copyright © 2014. Elsevier. All rights reserved.

For children with significant loss of hand function, therapists cerebral palsy and minimal control of extremity movements,
and families select adapted techniques and assistive technology particularly in midranges, often need switches or adapted inter-
to increase their participation in play, self-care, and school faces to access computers, tablets, and other devices.84 Exam-
activities. Although technology is used to support hand func- ples of assistive technology for children with severe cerebral
tion for children with a broad range of disabilities, to illustrate palsy and limited hand function are described in the following
how technologies can support play, self-care, and school occu- sections.
pations, this section focuses on three types of children. Chil-
dren and youth with (1) orthopedic conditions that restrict
Assistive Technology to Enhance Children’s
upper extremity function, (2) neuromuscular disorders with Participation in Play Activities
significant weakness or loss of movement, and (3) cerebral palsy Children with severely limited upper extremity ROM or hand
with severe spasticity and limited ROM often benefit from function can increase their participation in play activities with
adapted techniques and assistive technology. application of assistive technology.77 Lane and Mistrett77 rec-
Children born with congenital orthopedic disorders, such ommend the family access lending libraries to explore different
as arthrogryposis, may have significant limitations in hand options in adapted toys and play activities. Toy adaptations

Case-Smith, J., & O'Brien, J. C. (2014). Occupational therapy for children and adolescents. Retrieved from http://ebookcentral.proquest.com
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 250 SECTION  III Occupational Therapy Intervention: Performance Areas

TABLE 8-10 Switches and Computer Devices for Children with Limited Hand Function
Switch or Device Examples of Use Functionality Required to Operate

Button switch Operates a battery powered toy; can The child presses down with hand or arm. Releases
interface with a computer; can be by lifting hand and arm
used with online scanning Can operate with fist or open hand
Grasp switch Turns devices on and off, can interface The child squeezes the switch using palmar grasp.
with computer and operate online Must be able to release the grip to prevent
scanning; operates a battery- switch latching
powered toy
Ribbon or leaf switch Turns devices on and off; operates a The child activates by swiping against the switch and
battery-powered toy bending it. A child who reaches and swipes with
fair accuracy can operate this switch.
Plate switch Turns on and off other devices; operates The child activates with very light touch. A child
a battery-powered toys with poor strength and minimal hand movement
can activate this switch.
Joystick Turns devices on and off; can be used as The child can operate without full grasp if
the computer’s mouse; because it has positioned in thumb web space. Usually the full
directionality can be used to operate arm is used to push the joystick forward and
a power wheelchair backward. Backward pull requires grasp, but child
with minimal strength can operate a joystick.
Child must have directionality sense. Sensitivity of
joystick can be adjusted for a child with poor
control of arm movements.
Head proximity switches, Turns devices on and off; can include For a child with no hand movement or extremely
mouth-activated switches activate computer poor control of arm and hand movement, the
(e.g., pneumatic) head or mouth can be used to activate a switch.
Adapted mouse: joystick Provides mouse functions For a child with poor control of arm movement or
limited grasp. Child controls the mouse
movement by moving joystick in different
directions. Joystick can be calibrated to become
more or less responsive to child’s movements.
Adapted mouse: trackball Provides mouse functions For a child with limited hand strength and
movement, or a child with limited arm control.
Computer’s cursor moves with minimal movement
of hand on trackball.
BigKeys keyboard Provides large, easily visible keys to For a child with limited fine motor control who
access the computer’s keyboard needs a bigger key target. Child with poor hand
coordination or ataxia is more accurate with
BigKeys.
Membrane keyboard Provides alternative keyboard for For a child with poor strength and limited arm and
computer access and word processing hand movement

See Ablenet at http://www.ablenetinc.com.

include easy-to-grasp handle extensions or handles on puzzle different types of switches and the arm and hand function
pieces, methods to stabilize the toy by placing on a nonslip required to activate them.
material or materials, and attaching toys to the hand using
Velcro or a strap. Campbell et al.14 summarized 12 studies that Adapted Equipment for Activities of Daily Living
Copyright © 2014. Elsevier. All rights reserved.

examined young children’s use of switches to activate toys or For children with limited reach, grasp, and manipulation, use
a computer. These studies demonstrated that young children of adapted equipment and simple devices can significantly
with a variety of disabilities can learn to use a switch and that increase their independence in ADLs. When selecting adapted
switch-activated toys are motivating and reinforcing. Children equipment to improve the child’s participation in ADLs, the
with minimal arm and hand function can activate switches using occupational therapist selects and recommends devices that the
an arm swipe, full hand grasp, or pressing motion with hand child can (1) easily use to achieve the ADL goal with minimal
open. Once a reliable and controlled arm or hand movement caregiver supports, (2) independently don and doff, (3) learn
is identified, an appropriate switch is selected and placed opti- to use without extensive training, and (4) use in different cir-
mally for the child to activate. When a child can consistently cumstances and environments. The device or adapted materials
activate a switch, it can be used to operate different battery- need to easily fit into the family daily life and should be durable
operated toys and computer play activities. For children with and reliable. Examples of adapted equipment that can support
limited reach and minimal manipulation, switch-activated toys a child eating independently include Dycem underneath the
can offer an engaging and meaningful play activity that rein- plate to stabilize it, a scoop bowl that allows easy scooping
forces the child’s motivation and self-initiation. Table 8-10 lists with a spoon, a spoon or fork with built-up handle, bent

Case-Smith, J., & O'Brien, J. C. (2014). Occupational therapy for children and adolescents. Retrieved from http://ebookcentral.proquest.com
Created from uql on 2018-04-19 19:31:44.