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ISBN-13: 978-0323-03186-8
ISBN-I0 : 0-323-03186-2
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The Publ isher
ELSEY [ER
r.,~:~:,~,,~~,~
S a bre Foundation
CONTRIBUTORS
Dorit Haenosh Aaron, MA, OTR, CHT, FAOTA
Coordinator
Hand Therapy Fellowship
Department of Occupational Therapy
Texas Womens University
Houston, Texas
Mary Benbow, MS, OTR
Private Consultant and Lecturer
La Jolla, California
Jane Case-Smith, EdD, OTR/L, FAOTA
Professor
Division of Occupational Therapy
The Ohio State University
School of Allied Medical Professions
Columbus, Ohio
Sharon A. Cermak, EdD, OTR/L, FAOTA
Professor of Occupational Therapy
Department of Rehabilitation Sciences
Boston University, Sargent College;
Director of Occupational Therapy Training
Leadership and Education in Neurodevelopment
Disabilities
Childrens Hospital and University of
Massachusetts Medical Center
Boston, Massachusetts
Ann-Christin Eliasson, PhD, OT
Associate Professor
Neuropsychiatric Research Unit
Institution of Woman and Child Health
Karolinska Institute
Stockholm, Sweden
vi
Contributors
vii
viii
ACKNOWLEDGMENTS
The editors wish rst to acknowledge with gratitude
the time and expertise donated by the contributors to
this volume. These authors are highly regarded in their
respective elds, and we thank them for their insights
and the wealth of practical and theoretical understanding they bring through their chapters. We hope
that the diversity of ideas presented here will enrich the
readers understanding and appreciation of the immense complexity and the multiple dimensions of the
human hand and particularly of its importance to daily
living from birth through adolescence.
This book is the culmination of the efforts of many
people who contributed ideas over an extended period
of time. The formal beginnings of the book occurred
during a series of workshops for occupational and
physical therapists funded by the Maternal and Child
ix
Chapter
CORTICAL CONTROL OF
HAND-OBJECT INTERACTION
Charlane Pehoski
CHAPTER OUTLINE
MOVING THE FINGERS INDEPENDENTLY: DIRECT
CORTICOSPINAL CONNECTIONS TO ALPHA
MOTOR NEURONS OF THE HAND AND PRIMARY
MOTOR CORTEX
Direct Corticospinal Connections to Alpha Motor
Neurons of Hand Muscles
Primary Motor Cortex
Use-Dependent Organization of the Primary Motor
Cortex
SENSORY GUIDANCE OF HAND MOVEMENTS:
PRIMARY SOMATOSENSORY CORTEX
Cortical Organization of the Somatosensory System
Use-Dependent Organization Within the Primary
Somatosensory Cortex
Role of Somatosensory Input in Grasp
Role of Somatosensory Cortex in Motor Learning
THE TRANSFORMATION OF VISUALLY OBSERVED
CHARACTERISTICS ABOUT OBJECTS INTO
APPROPRIATE HAND CONFIGURATIONS:
POSTERIOR PARIETAL LOBE AND VENTRAL
PREMOTOR CORTEX
Role of the Inferior Parietal Lobe in Preshaping of
the Hand
Role of the Ventral Premotor Cortex in Preshaping
of the Hand
Use-Dependent Organization of the Inferior Parietal
and Ventral Premotor Cortex
The Inferior Parietal Cortex and Tool Use
SUMMARY AND THERAPEUTIC IMPLICATIONS
When I rst met Katie she was 6 years old and was
having a great deal of difculty managing the ne motor
tasks typical of most kindergarten children. She was
clumsy and had difculty with such tasks as buttoning
and using tools. Her score on the Peabody Developmental
Fine Motor Scales was 2.33 standard deviations below
the mean for her age and her age equivalent score was
3 years 6 months. This is not an unusual prole for
children referred because of poor ne motor skills.
What was unique about Katie was that the source of
her difculty was known. A benign tumor had been
removed from her right posterior parietal lobe when
she was 3 years old. Many of the difculties she experienced in handobject interaction could be attributed to
the location of her lesion. For example, she was underresponsive to tactile input and often used excess force
when holding objects. When asked to feel forms placed
in her hand without looking, she just grasped them and
did not explore them with her ngers. She had a great
deal of difculty in tasks that required in-hand manipulation, such as moving a small object from the palm
of the hand to the ngers. Objects often were dropped.
This chapter discusses the posterior parietal lobe and its
importance for handobject interaction. However, this
is not the only important area; other cortical regions
are also explored.
The capacity to use the hand with skill in hand
object interactions represents an evolutionary ability
characteristic of the behavior of higher primates. Three
fundamental prerequisites are necessary for this function: (a) the capacity for independent control over the
ngers, (b) a sophisticated somatosensory system to
guide nger movements, and (c) the ability to transform sensory information concerning object properties
into appropriate hand congurations (Binkofski et al.,
1999). Each of these prerequisites is served by separate
Corticospinal tract
Direct corticospinal input
Indirect corticospinal input
Interneuron zone
Muscle of distal
extremity
Figure 1-2
11.5mm
9.5mm
13.5mm
19.5mm
26mm
LH
The primary receiving area for somatosensory information from the limbs is the area of cortex just behind the
central gyrus. This area generally is called the primary
somatosensory cortex (Figure 1-6). It is the major termination of the dorsal columns, which carries discrete
somatosensory information from the periphery. This
major tract has evolved in parallel with the corticospinal
tract, and like this system it reaches it highest level of
development in humans (Paillard, 1993). Information
carried in the dorsal columns can register even small
movements of joints and provide knowledge of the
exact location of stimulus on the skin. It was designed
to provide specic information about what is happening in the periphery.
In both monkeys (Sakata & Iwamura, 1978) and
humans (Moore et al., 2000) the primary somatosensory cortex is composed of four areas, generally called
Brodmanns areas 3a, 3b, 1, and 2 (see Figure 1-6). An
understanding of the function of the primary somatosensory area is helpful to appreciate the complexity of
information processing within this area, particularly for
the hand.
Afferent bers from the dorsal columns project
mainly to area 3b for cutaneous input and area 3a for
IPSI
CONTRA
Figure 1-5 Disruption of finger coordination after inactivation of area 2 in a monkey. The sequence of movements (left
to right) shows the animals attempts at picking up a piece of apple from a funnel. IPSI indicates the normal hand
ipsilateral to the inactivated region. CONTRA indicates the disorganized movements of the affected hand contralateral to
the inactivated region. (Redrawn from Hikosaka O, Tanaka M, Sakamoto M, Iwamura Y [1985]. Deficits in manipulative behaviors
induced by local injection of muscimol in the first somatosensory cortex of the conscious monkey. Brain Research,
325:375380.)
10
3a
3b 1 2
Primary
somatosensory
cortex
Central
sulcus
2
1
3b
3a
and felt that at least in some (e.g., former typist, appliance repairman) these differences might be related to
the individuals premorbid occupation. In a more recent
study, Hashimoto et al. (2004) used noninvasive techniques to study the somatosensory cortex in string
players. They found an enlarged cortical representation
of the hand area in these individuals compared with
controls who did not play a string instrument.
Like the motor cortex, research seems to indicate
that skilled learning or attention to a task may be particularly effective in mediating these cortical changes.
Using a behavioral task similar to the one used for
studying the changes in the motor cortex of monkeys,
animals were trained to pick up food pellets placed in
wells of varying diameters (Xerri et al., 1999). This
included large-diameter wells in which the pellets were
easy to retrieve, and smaller-diameter wells in which
retrieval was more difcult. The researchers found that
sensory neurons responsive to the specic nger surfaces that had been engaged in the small retrieval task
showed major representative changes within area 3b
of the somatosensory cortex that were not seen with
other nger surfaces. That is, changes reflected digital
surfaces that were necessary for object retrieval under
12
THE TRANSFORMATION OF
VISUALLY OBSERVED
CHARACTERISTICS ABOUT
OBJECTS INTO APPROPRIATE
HAND CONFIGURATIONS:
POSTERIOR PARIETAL LOBE AND
VENTRAL PREMOTOR CORTEX
Think for a moment what it would be like if one had
an excellent mechanism for the control of nger
movements and somatosensory feedback to guide the
movements but did not have a mechanism for selecting
the grasp appropriate for a particular object. There
would be a lot of trial and error. Movements would be
slow. A glass would be approached in the same way as
a fork. The hand would land on an object and then
feel for the appropriate grasp. One function that
would help would be vision. Up until now vision has
not been considered. The primary motor cortex has
limited access to direct visual information (Jeannerod
et al., 1995). Vision allows for the preparation of grasp
before contact; therefore the hand could be preshaped
to match objects of different shapes, sizes, and orientation. Any nal adjustments could be made by
somatosensory feedback on contact. This preshaping of
the hand is one of the functions provided by a posterior
parietal cortexprefrontal lobe cortex circuit.
Central sulcus
Primary
somatosensory
cortex
Superior
parietal
lobe
Primary motor
cortex
Ventral premotor
cortex
Central sulcus
Intraparietal
sulcus
14
Figure 1-9 Spontaneous hand use of a woman with a bilateral disturbance of the posterior parietal lobe as she
attempts to use a: (A) lighter, (B) nail clipper, (C) soup spoon, and (D) scissors (successive attempts). (Redrawn from
Sirigu A, Cohen L, Duhamel J, Pillon B, Dubois B, Agid Y [1995]. A selective impairment of hand posture for object utilization in
apraxia. Cortex, 31:4155.)
ventral premotor area, which also appears to be important for hand use. There is one other function of the
parietal lobe related to object interaction that should be
mentioned, the guidance of movements when exploring an object manually. The term tactile apraxia has
been used to dene a problem in this area (Pause et al.,
1989). In patients with tactile apraxia, exploratory
movements are described as slow and clumsy and may
consist of only squeezing the object (Binkofski et al.,
2001; Pause & Freund, 1989; Valenza et al., 2001).
This problem has been seen in a variety of parietal
lesions (Binkofski et al., 2001; Pause & Freund, 1989;
Valenza et al., 2001), including the primary somatosensory cortex (Motomura et al., 1990; Tomberg &
Desmedt, 1999). The problem does not appear to be
related to the severity of any somatosensory disturbances that might be present. That is, a patient with a
signicant sensory loss may be better able to manipulate an object for identication than a patient with
better-preserved sensation (Pause et al., 1989; Valenza
et al., 2001). Problems moving her nger around
objects in a manual form identication task was one
area with which Katie had difculty. She tended to just
16
table
Food dispenser
Figure 1-10 A. Monkey using a rake to obtain a food pellet that was dispensed out of its reach from a container. B.
Simple stick manipulation task in which the food pellet was delivered at a reachable distance as a reward for swinging
the stick. (Redrawn from Obayashi S, Suhara T, Kawabe K, Okauchi, Maeda J, Akine Y, Onoe H, Iriki A (2001): Functional brain
mapping of monkey tool use, Neuroimage 14: 853-861.)
3
1
2
Dorsal column
Corticospinal
tract
Figure 1-11 A. Diagram of a somatosensory and a primary motor cortex circuit. (1) A message from the primary motor
cortex is sent to the muscles via the corticospinal tract; (2) sensory feedback is sent through the dorsal column as a
result of the movement (3) of sensory input to the primary somatosensory cortex; (4) sensory information is sent from
the primary sensory cortex to the primary motor cortex for any necessary correction of the movement. B. Diagram of
somatosensory, inferior parietal lobe, ventral premotor cortex, and motor cortex circuit. (1) Sensory information is sent to
the inferior parietal lobe; (2) visual information also is transferred to the inferior parietal lobe; (3) information from the
inferior parietal lobe is sent to the ventral premotor cortex; (4) the ventral premotor area transfers information to the
primary motor cortex and from there to the corticospinal tract.
REFERENCES
Ageranioti-Belanger SA, Chapman CE (1992). Discharge
properties of neurons in the hand area of primary
somatosensory cortex in monkeys in relation to the
performance of an active tactile discrimination task. II.
Area 2 as compared with areas 3b and 1. Experimental
Brain Research, 91:207228.
Asanuma H, Pavlides C (1997). Neurobiological basis of
motor learning in mammals. Neuroreport, 8:ivi.
18
20
Chapter
CHAPTER OUTLINE
EMBRYONIC DEVELOPMENT
EMBRYONIC DEVELOPMENT
One cannot expect to adequately understand the development and function of the hand and arm without
a solid working knowledge of the intricate anatomic
and kinesiologic relationships of the upper extremity,
including the embryonic growth stages through which
the extremity progresses. Only through comprehension
of the normal formation and anatomy of the human
hand can one adequately develop an appreciation for
the disturbance in function that accompanies injury,
disease, or dysfunction. It is appropriate, therefore
that an early chapter in a book devoted to development
of ne motor coordination be concerned with the
embryology, anatomy, kinesiology, and biomechanics
of the hand. Because it is impossible in this chapter
to review in great detail the enormous amount of
literature that has been written about these elds of
knowledge, readers are directed to the Suggested
Readings.
21
22
OSSEOUS STRUCTURES
The unique arrangement and mobility of the bones of
the hand (Figure 2-1) provide a structural basis for its
enormous functional adaptability. The osseous skeleton
consists of eight carpal bones divided into two rows:
The proximal row articulates with the distal radius and
ulna (with the exception of the pisiform, which lies
palmar to and articulates with the triquetrum); the
distal four carpal bones in turn articulate with the ve
Distal phalanx
Middle phalanx
Proximal phalanx
Metacarpal
Hamate
Pisiform
Triquetrum
Trapezoid
Capitate
Trapezium
Scaphoid
Lunate
Hamate
Triquetrum
Figure 2-1 Bones of the right hand. A. Palmar surface. B. Dorsal surface. (From Fess EE, Gettle K, Philips CA, et al. [2005].
Hand and upper extremity splinting. St Louis, Mosby.)
Proximal
transverse
arch
Distal
transverse arch
Longitudinal
arch
Figure 2-2 A. Skeletal arches of the hand. The proximal transverse arch passes through the distal carpus; the distal
transverse arch, through the metacarpal heads. The longitudinal arch is made up of the four digital rays and the carpus
proximally. B. Proximal and distal transverse arches. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper
extremity splinting. St Louis, Mosby.)
osseous arches. Collapse in the arch system can contribute to severe disability and deformity. Flatt (1979,
1983, 1995) has pointed out that grasp is dependent
on the integrity of the mobile longitudinal arches
and when destruction at the carpometacarpal joint,
metacarpophalangeal joint, or proximal interphalangeal
joint interrupts the integrity of these arches, crippling
deformity may result.
JOINTS
The multiple complex articulations among the distal
radius and ulna, the eight carpal bones, and the
metacarpal bases comprise the wrist joint, whose proximal position makes it the functional key to the motion
at the more distal hand joints of the hand. Functionally
the carpus transmits forces through the hand to the
forearm. The proximal carpal row consisting of the
scaphoid (navicular), lunate, and triquetrum articulates
distally with the trapezium, trapezoid, capitate, and
hamate; there is a complex motion pattern that relies
both on ligamentous and contact surface constraints.
The major ligaments of the wrist (Figure 2-3) are the
palmar and intracapsular ligaments. There are three
strong radial palmar ligaments: the radioscaphocapitate
or sling ligament, which supports the waist of the
scaphoid; the radiolunate ligament, which supports the
lunate; and the radioscapholunate ligament, which connects the scapholunate articulation with the palmar
portion of the distal radius. This ligament functions
as a checkrein for scaphoid flexion and extension. The
ulnolunate ligament arises intra-articularly from the
triangular articular meniscus of the wrist joint and inserts
on the lunate and, to a lesser extent, the triquetrum.
The radial and ulnar collateral ligaments are capsular
ligaments, and V-shaped ligaments from the capitate to
24
Lunotriquetral ligament
Radioscaphocapitate
ligament
Vestigial ulnar
collateral ligament
Scapholunate
ligament
Radial collateral
ligament
Ulnocarpal
meniscus homologue
Radiolunate
ligament
(radiolunotriquetral)
Ulnolunate ligament
(ulnolunate-triquetral)
Radioscapholunate
ligament
(ligament of Testut
and Kuenz)
Td
Tm
P
Dorsal
intercarpal
ligament
Tq
S
L
Dorsal radiocarpal
ligament
(radiotriquetral)
5
6
Figure 2-3 Ligamentous anatomy of the wrist. A. Palmar wrist ligaments. B. Dorsal wrist ligaments. C. Dorsal view of
the flexed wrist, including the triangular fibrocartilage. 1, Ulnar collateral ligament; 2, retinacular sheath; 3, tendon of
extensor carpi ulnaris; 4, ulnolunate ligament; 5, triangular fibrocartilage; 6, ulnocarpal meniscus homologue; 7, palmar
radioscaphoid lunate ligament. P, Pisiform; H, hamate; C, capitate; Td, trapezoid; Tm, trapezium; Tq, triquetrum; L, lunate;
S, scaphoid. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby.)
Central
column
Medial
column
Lateral
column
First metacarpal
B
Figure 2-6 A. Multiple planes of motion (arrows) that
occur at the carpometacarpal joint of the thumb. B. The
thumb moves (arrow) from a position of adduction
against the second metacarpal to a position of palmar or
radial abduction away from the hand and fingers and can
then be rotated into positions of opposition and flexion.
(From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and
upper extremity splinting. St Louis, Mosby.)
26
Diarthrodial
(multiplane
motion)
Palmar plate
Membranous portion
of palmar plate
(folds in flexion)
Cord portion of
collateral ligaments
Cord portion of
collateral ligaments
Accessory collateral
ligament
Accessory collateral
Palmar
ligaments
Palmar
fibrocartilaginous
fibrocartilaginous
plates
plates
Collateral ligament
(tight in flexion)
Cord
Collateral ligament
Accessory
Palmar plate
Checkrein ligaments
Cord
Accessory
Checkrein
ligaments
Collateral ligament
Palmar plate
Extrinsic Muscles
The extrinsic flexor muscles (see Figure 2-11) of the
forearm form a prominent mass on the medial side of
the upper part of the forearm: The most supercial
group comprises the pronator teres, the flexor carpi
radialis, the flexor carpi ulnaris, and the palmaris longus;
the intermediate group the flexor digitorum supercialis; and the deep extrinsics the flexor digitorum
profundus and the flexor pollicis longus. The pronator,
palmaris, wrist flexors, and supercialis tendons arise
from the area about the medial epicondyle, the ulnar
collateral ligament of the elbow, and the medial aspect
of the coronoid process. The flexor pollicis longus
originates from the entire middle third of the palmar
surface of the radius and the adjacent interosseous
membrane, and the flexor digitorum profundus originates deep to the other muscles of the forearm from the
proximal two-thirds of the ulna on the palmar and
medial side. The deepest layer of the palmar forearm is
completed distally by the pronator quadratus muscle.
The flexor carpi radialis tendon inserts on the base of
the second metacarpal, whereas the flexor carpi ulnaris
inserts into both the pisiform and fth metacarpal base.
The supercialis tendons lie supercial to the profundus tendons as far as the digital bases, where they
bifurcate and wrap around the profundi and rejoin over
28
Composite
Superficial
Palmaris longus
Nerve: median
Action: tension of
palmar fascia
Pronator quadratus
Nerve: median
Action: forearm
pronation
Pronator
quadratus
Supinator
Pronator
teres
Supination
Pronation
Supinator
Nerve: radial
Action: forearm
supination
Brachioradialis
Pronator teres
Nerve: median
Action: forearm
pronation
Brachioradialis
Nerve: radial
Action: pronation or
supination, depending
on position of forearm
Figure 2-11 Extrinsic flexor muscles of the arm and hand. (Dark areas represent origins and insertions of muscles.)
(From Fess EE, Gettle K, Philips CA, et al. (2005). Hand and upper extremity splinting. St Louis, Mosby. Modified from Marble HC
[1960]. The hand, a manual and atlas for the general surgeon. Philadelphia, WB Saunders.)
Composite
Deep
Figure 2-11contd.
FDS
FDP
Camper's chiasma
FDS
30
Flexor digitorum
profundus
A-2
C-3
A-5
Digital flexor
sheath
Flexor digitorum
superficialis
Hypothenar
muscles
Sheath of
flexor pollicis
longus
Median nerve
Thenar muscles
Ulnar artery
Ulnar nerve
Transverse carpal
ligament
Radial artery
Extensor indicis
proprius
Nerve: radial
Action: extension of
index finger
Extensor pollicis
longus
Nerve: radial
Action: extension of
interphalangeal joint
and metacarpophalangeal
joint of thumb
Extensor carpi
ulnaris
Nerve: radial
Action: extension of
wrist and ulnar
deviation of hand
Composite
Extensor digitorum
communis and extensor
digiti quinti proprius
Nerve: radial
Action: extension of
fingers
Figure 2-15 Extrinsic extensor muscles of the forearm and hand. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand
and upper extremity splinting. St Louis, Mosby. Modified from Marble HC [1960]. The hand, a manual and atlas for the general
surgeon. Philadelphia, WB Saunders.)
Continued
Intrinsic Muscles
The important intrinsic musculature of the hand can be
divided into muscles comprising the thenar eminence,
those comprising the hypothenar eminence, and the
remaining muscles between the two groups (Figure
32
Abductor pollicis
longus
Nerve: radial
Action: abduction of thumb
Figure 2-15contd.
First dorsal
interosseous
Extensor digitorum
communis
Extensor
indicis proprius
Extensor
pollicis brevis
Extensor carpi
radialis
longus and brevis
1 2 3
5 6
Abductor
pollicis
longus
Figure 2-16
Opponens pollicis
Nerve: median
Action: rotation of first
metacarpal toward palm
Adductor pollicis
Nerve: ulnar
Action: adduction
of thumb
Figure 2-17 Intrinsic muscles of the hand. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity
splinting. St Louis, Mosby. Modified from Marble HC [1960]. The hand, a manual and atlas for the general surgeon. Philadelphia,
WB Saunders.)
Continued
34
Lumbricals
Nerve: medianindex and long
ulnarring and small
Action: supplements metacarpophalangeal
flexion and extension of proximal and
distal interphalangeal joints
Dorsal
interossei
Composite
Dorsal interossei
Nerve: ulnar
Action: spread of
index and ring fingers
away from long finger
All interossei
Nerve: ulnar
Action: flexion of
metacarpophalangeal
joints and extension of
proximal and distal
interphalangeal joints
Palmar
interossei
Palmar interossei
Nerve: ulnar
Action: adduction
of index, ring, and
fifth fingers
toward long finger
Figure 2-17contd.
Adductor
pollicis
Opponens
digiti quinti
Abductor
pollicis brevis
Flexor digiti
quinti
Flexor pollicis
brevis
Transverse carpal
ligament
Opponens
pollicis
Abductor digiti
quinti
Flexor carpi
ulnaris
Pronator
quadratus
Abductor
digiti
minimi
Dorsal
interossei
(1 to 4)
Ulnar nerve
Palmar
interossei
(1 to 3)
1
B
Figure 2-18
36
Radial
Triangular ligament
Lateral band
Slip of
long extensor
to lateral band
Sagittal bands
Lumbrical muscle
Long extensor tendon
Interosseous muscle
A
Long extensor tendon
Interosseous muscle
Sagittal bands
Interosseous
muscle
Lumbrical muscle
Distal movement of
extensor expansion
during flexion
Lateral band
C
Figure 2-19 A. Extensor mechanism of the digits. B, C. Distal movement of the extensor expansion with
metacarpophalangeal joint flexion is shown.
0 mm
3 mm
16 mm
26 mm (S)
23 mm (P)
16 mm (S)
17 mm (P)
44 mm
55 mm
5 mm (P)
46 mm (S)
38 mm (P)
88 mm (S)
85 mm (P)
N ERVE SUPPLY
In considering the nerve supply to the forearm, hand,
and wrist, understand that these nerves are a direct
continuation of the brachial plexus and that at least a
working knowledge of the multiple ramications of the
38
Table 2-1
MA
Normal
Muscle
Mkg
0.8
1.1
PTE
A-4
C-1 A-3 C-2 C-3 A-5
IAPD
A-1
A-2
IAPD
PTE
90
0.9
B
1.1
0.1
1.2
4.5
4.8
Brachioradialis
1.9
2.0
Pronator teres
1.2
Palmaris longus
0.1
0.1
1.7
Abnormal
MA
1
%
2 A-4
1
%
2 A-2
IAPD
PTE
PTE
IAPD
90
D
Figure 2-21 Biomechanics of the finger flexor pulley
system. A. The arrangement of the annular and cruciate
pulleys of the flexor tendon sheath. A, B, Normal
moment arm (MA), the intra-annular pulley distance
(IAPD) between the A-2 and A-4 pulleys, and the
profundus tendon excursion (PTE), which occurs within
the intact digital fibroosseous canal as the proximal
interphalangeal joint is flexed to 90. Annular pulleys:
A-1, A-2, A-3, A-4, and A-5; cruciate pulleys: C-I, C-2, C-3.
C, D, Biomechanical alteration resulting from excision of
the distal half of the A-2 pulley together with the C-1,
A-3, C-2, and proximal portion of the A-4 pulley. The
moment arm is increased, and a greater profundus
tendon excursion is necessary to produce 90 of flexion
because of the bowstringing that results from the loss of
pulley support. (From Fess EE, Gettle K, Philips CA, et al.
[2005]. Hand and upper extremity splinting. St Louis, Mosby.
Modified from Strickland JW [1983]. Management of acute
flexor tendon injuries. Orthopaedic Clinics of North America,
vol 14. Philadelphia, WB Saunders.)
Median
Median
Median
Ulnar
Radial
Radial
Ulnar
nerve
Median
nerve
Superficial branch
of radial nerve
Figure 2-22 Cutaneous distribution of the nerves of the hand. A. Palmar surface. B. Dorsal surface. (From Fess EE, Gettle
K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby.)
40
Proper
palmar digital
nerves
Common
digital
nerves
Palmar nerves
to thumb
Motor (thenar)
branch of
median nerve
Median nerve
Proper palmar
digital nerves
Motor (deep)
branch of ulnar
nerve
Ulnar nerve
B
Figure 2-23 Distribution of the median (A) and ulnar
(B) nerves in the palm. (From Fess EE, Gettle K, Philips CA,
et al. [2005]. Hand and upper extremity splinting. St Louis,
Mosby.)
The palmar skin with its numerous small brous connections to the underlying palmar aponeurosis is a
highly specialized, thickened structure with little
mobility. Numerous small blood vessels pass through
the underlying subcutaneous tissues into the dermis. In
contrast, the dorsal skin and subcutaneous tissue are
much looser with few anchoring bers and a high
degree of mobility. Most of the lymphatic drainage
from the palmar aspect of the ngers, web areas, and
hypothenar and thenar eminences flows in lymph
channels on the dorsum of the hand. Clinical swelling,
which frequently accompanies injury or infection, is
usually a result of impaired lymph drainage.
The central, triangularly shaped palmar aponeurosis
(Figure 2-24) provides a semirigid barrier between the
palmar skin and the important underlying neurovascular and tendon structures. It fuses medially and
laterally with the deep fascia covering the hypothenar
and thenar muscles, and fasciculi extending from this
thick fascial barrier extend to the proximal phalanges to
fuse with the tendon sheaths on the palmar, medial,
and lateral aspects. In the distal palm, septa from this
palmar fascia extend to the deep transverse metacarpal
ligaments forming the sides of the annular brous
canals, allowing for the passage of the ensheathed flexor
tendons and the lumbrical muscles and the neurovascular bundles.
Palmar aponeurosis
(reflected)
Flexor digitorum
superficialis
Sheath of flexor
pollicis longus
Ulnar
artery
Ulnar
nerve
Median nerve
Thenar muscles
Transverse
carpal ligament
FUNCTIONAL PATTERNS
The prehensile function of the hand depends on the
integrity of the kinetic chain of bones and joints extending from the wrist to the distal phalanges. Interruptions
of the transverse and longitudinal arch systems formed
by these structures always result in instability, deformity, or functional loss at a more proximal or distal
level. Similarly, the balanced synergismantagonism
relationship between the long extrinsic muscles and the
intrinsic muscles is a requisite for the composite functions necessary for both power and precision functions
of the hand. It is essential to recognize that the hand
cannot function well without normal sensory input
from all areas.
Many attempts have been made to classify the different patterns of hand function, and various types of
grasp and pinch have been described. Perhaps the
more simplied analysis of power grasp and precision
handling as proposed by Napier (1955, 1956) and
rened by Flatt (1979, 1983, 1995) is the easiest to
consider.
42
the index nger tip to the tip of the small nger, and
the adaptation that occurs between the thumb and
digits as progressively smaller objects are held occurs
primarily at the metacarpophalangeal joints of the digits
and the carpometacarpal joint of the thumb.
For power grip the wrist is in an extended position
that allows the extrinsic digital flexors to press the
object rmly against the palm while the thumb is closed
tightly around the object. The thumb, ring, and small
ngers are the most important participants in this
strong grasp function, and the importance of the ulnar
border digits cannot be minimized (Figure 2-26).
In precision grasp, wrist position is less important,
and the thumb is opposed to the semiflexed ngers
with the intrinsic tendons providing most of the nger
movement. When the intrinsic muscles are paralyzed,
the balance of each nger is markedly disturbed. The
metacarpophalangeal joint loses its primary flexors, and
the interphalangeal joints lose the intrinsic contribution to extension. A dyskinetic nger flexion results in
which the metacarpophalangeal joints lag behind the
interphalangeal joints in flexion. When the hand is
closed on an object, only the ngertips make contact
rather than the uniform contact of the ngers, palm,
and thumb that occurs with normal grip (Figure 2-27).
Certain activities may require combinations of
power and precision grips, as seen in Figure 2-28.
Pinching between the thumb and either the index or
long nger is a further renement of precision grip and
may be classied as tip grip, palmar grip, or lateral grip
(Figure 2-29), depending on the portions of the phalanges brought to bear on the object being handled. In
these functions the strong contracture of the adductor
pollicis brings the thumb into contact against the tip or
sides of the index or index and long ngers with digital
B
Figure 2-27 A. Normal hand grasping a cylinder.
Uniform areas of palm and digital contact are shaded.
B. Intrinsic minus (claw hand grasping the same
cylinder). The area of contact is limited to the fingertips
and the metacarpal heads. (From Brand PW [1999]. Clinical
mechanics of the hand, 2nd ed. St Louis, Mosby.)
REFERENCES
ACKNOWLEDGMENTS
I am extremely grateful to Gary W. Schnitz for many of
the excellent illustrations used in this chapter. This
chapter has been edited by Elaine Ewing Fess, MS,
OTR, FAOTA, CHT for inclusion in this book. The
44
SUGGESTED READINGS
Chase RA (1973). Atlas of hand surgery. Philadelphia, WB
Saunders.
Chase RA (1984). Atlas of hand surgery, vol. 2.
Philadelphia, WB Saunders.
Clemente CD (editor) (1990). Grays anatomy of the human
body, 14th ed. Philadelphia, Lea & Febiger.
Hollingshead HW (editor) (1982). Anatomy for surgeons,
vol 4. The back and limbs. New York, Harper & Row.
Chapter
CHAPTER OUTLINE
DEVELOPMENT OF MOVEMENT CONTROL
THEORIES
LEARNED MOVEMENTS
AFFERENT INFORMATION
Proprioception
Touch
BASIC COORDINATION OF FORCES DURING
GRASPING
Development of Manipulatory Forces
DEVELOPMENT OF ANTICIPATORY CONTROL
Weight
Size
Friction
ORGANIZATION OF SENSORIMOTOR CONTROL
IMPAIRED FORCE CONTROL AND CLINICAL
IMPLICATIONS
Force Coordination
Anticipation of the Properties of Objects
Sensory Information Used for Force Control
SUMMARY
45
46
Sensorimotor system
Cognition
Task-comprehension
Perception
Attention
Task-focus
Hand use
Muscles and
skeletal system
Self-efficacy
Figure 3-1 Descriptive illustration of components influencing childrens ability to use their hands. (From Eliasson AC
(2004). Improving the use of the hands in daily activities: aspects of the treatment of children with cerebral palsy. Physical and
Occupational Therapy in Pediatrics, 25:3760.)
DEVELOPMENT OF MOVEMENT
CONTROL THEORIES
At the beginning of this century, sensory stimuli were
thought to be responsible for the generation of movements. This concept was based on studies by Mott
and Sherrington (1895) on deafferented monkeys. By
transecting the dorsal roots, researchers cut sensory
fibers and left the motor fibers intact. The complete
sensory loss resulted in permanent abolishment of
almost all voluntary movements, especially in the distal
segments. A model was proposed in which the movements were generated by chain reflexes; the sensory
information from the first muscle contraction elicited
the subsequent spinal reflex.
This reflex origin of movement was disputed by
Brown (1911), who studied locomotion in spinal cats.
He suggested instead a central origin in which neuronal
networks could generate basic locomotor activity in the
absence of sensory information (half center model).
The task of the afferents was restricted to modifying
and compensating for ongoing movements. However,
it took quite a long time before this idea was confirmed. Nowadays there are several elegant studies that
indicate that innate neural networks control rhythmic
motor behavior in a variety of species such as locusts,
lampreys, and cats (Forssberg, Grillner, & Halbertsma,
1980; Forssberg et al., 1980; Grillner, Wallen, & Brodin,
1991; Wilson, 1964). Neural networks, called central
pattern generators (CPGs), consist of a group of interneurons that interact in an organized manner to produce a motor act. Detailed knowledge of how one CPG
operates has been demonstrated in the lamprey, a primitive vertebrate fish. The lamprey is especially suited for
such studies because the spinal cord survives in vitro for
several days, and neurons involved in the locomotor
network for swimming are visible under the micro-
LEARNED MOVEMENTS
Voluntary movements in humans are complex. It is
difficult to demonstrate a simple fixed pattern from a
CPG, although skilled movements appear to depend on
a set of motor programs. According to Brooks (1986),
Motor programs are a set of muscle commands that are
structured before the motor acts begin and that can be sent to the
muscles with the correct timing so that the entire sequence can be
carried out in the absence of peripheral feedback (p. 7),
or, in other words, can follow an initial plan. In welllearned, fast movements the trajectory exactly follows
this initial plan. The initiation and termination are
AFFERENT INFORMATION
The importance of afferent information is seen in
patients with large sensory fiber neuropathies, in which
the large afferent fibers generating proprioceptive and
tactile information degenerate. Unless these patients
see their limbs, they do not know their position and
cannot detect limb motion. When reaching toward a
target without seeing the moving hand, they make
large errors; if they look at the hand before reaching,
the hand comes closer to the target. This indicates that
these patients can compensate for the lack of somatosensory information visually and also use vision to
program the reaching in advance. Because the patients
cannot stop the movement precisely at the desired
48
PROPRIOCEPTION
The proprioceptive system gives information about the
stationary position of the limbs (limb position sense)
and movements of the limb (kinesthesia). The latter
information is mediated from tendon organs and muscle spindles and also from receptors in the skin, sensitive
to skin stretch. The tendon organ signals information
about the strength of muscle contraction, increased
signaling indicating increased tension. Signals from the
muscle spindle regulate the length of the muscle fibers.
The receptors are rather complicated and, despite intensive research, their function is not fully understood. It
has been agreed, however, that the muscle spindle is
responsible for small changes in muscle contraction,
which may be important for force regulation during the
grasping act. There are muscle spindles in almost all
skeletal muscles, and they mediate information mainly
through 1a afferents to the spinal cord. The muscle
spindle also has efferent innervation to intrafusal muscle fibers, in which the primary and secondary endings
set the sensitivity to the afferent signals. The different
contractions of intrafusal muscle fibers are probably
crucial for the information sent to the CNS. Alpha and
gamma motor neurons are co-activated by central
mechanisms to maintain the sensitivity of the muscle
spindles throughout the range of almost all movements. There have been different models for the coactivation of alpha and gamma motor neurons, but it
appears that descending commands activate both, as
demonstrated by Vallbo (1970) in studies of microneurography. The afferent signals are used to update
and correct the motor programs, and the information
can be used in a conscious way to give knowledge
about the limb movement and position in space.
TOUCH
The tactile system is used to discriminate between
different surfaces and shapes and also provides sensory
input to the CNS, which regulates the force of the
muscles during grasping and holding of objects. Touch
transmits nerve impulses from mechanoreceptors to the
CNS via axons with different diameters. Large fibers
with a fast conduction rate mediate tactile sensation
from the skin, whereas thin fibers with a slow conduction rate mediate sensation of pain and temperature. The receptors mediating tactile sensation can be
classified on the basis of their receptive fields and
Figure 3-2
stand how they are linked to produce smooth movements. When grasping the instrument, there is a short
delay before the vertical load force starts to increase.
This preload phase is important for establishment of
the grasp. During the loading phase the grip and load
forces increase in parallel until the instrument starts to
move. The rates of grip and load forces have mainly
bell-shaped profiles (see later discussion) adjusted to
Figure 3-3 Experimental instrument in which the grip surfaces are exchangeable and the weight can be covaried
without any visual changes.
50
1 Year
6 Years
Adult
4N
Grip Force, N
Load Force, N
2N
Position, mm
40 mm
Grip Force
Rate, N/S
40 N/S
Cerebral Palsy
Grip Force
3N
Load Force
3N
Grip Force
Rate, N/S
40 N/S
0.2s
Figure 3-4 Superimposed traces of representative lifts performed at different ages and in three children with cerebral
palsy with various degree of severity. Grip force, load force, position, and grip force rate are shown as functions of time.
When lifting the object, the grip force starts to increase; then the grip force and load force increase until the object starts
to move. When the forces overcome gravity, the signal measuring position increases, followed by a static phase when the
object is held in the air. (Modified from Forssberg H, Eliasson AC, Kinoshita H, Johansson RS, Westling G [1991]. Development
of human precision grip. I. Basic coordination of force. Experimental Brain Research, 85:451457; Forssberg H, Eliasson AC,
Redon-Zouiteni C, Mercuri C, Dubowitz L [1999]. Impaired grip-lift synergy in children with unilateral brain lesions. Brain,
122:11571168.)
Grip Force
2N
Load Force
2N
8 Months
2 Years
Adult
4N
DIPLEGIA
HEMIPLEGIA
Figure 3-5 Grip force during the preload and the loading phase (before lift-off) is plotted against load force in children
of different ages and children with cerebral palsy. Trials are superimposed for each subject. (Modified from Forssberg H,
Eliasson AC, Kinoshita, H, Johansson RS, Westling G [1991]. Development of human precision grip. I. Basic coordination of force.
Experimental Brain Research, 85:451457; Eliasson AC, Gordon AM, Forssberg H [1991]. Basic coordination of manipulative
forces in children with cerebral palsy. Developmental Medicine and Child Neurology, 33:661670.)
52
DEVELOPMENT OF ANTICIPATORY
CONTROL
Peak Grip Force Rate (N/s)
100
SIZE
Anticipatory control also is predicted from visual information about an objects size (Gordon et al., 1991a,b).
When the object is kept proportional to the volume,
60
40
20
WEIGHT
When the weight of the object is varied but the visual
appearance remains constant, adults typically scale the
grip and load force rates based on earlier experience of
the objects weight. This is indicated by higher grip and
load force rates for heavier objects. The forces are
decreased at lift-off to harmonize with the weight of
the object. The anticipatory mechanism can be further
demonstrated when lifting an unexpectedly light
object. For example, if one lifts an unopened but empty
can of soda, the lift will probably be too high because a
heavier can is expected. However, this occurs only once
for the same can. Somatosensory information adjusts
the forces to the objects actual weight during the static
phase and updates the internal representation of the
object for a smooth movement the next time the object
is lifted.
Children cannot handle this type of situation as
efficiently as adults. However, despite uncoordinated
force generation and large variation of grip and load
force rates, 2-year-old children start to scale the forces
toward different weights. It takes several years until
the anticipatory control of weight is fully developed.
Children between the ages of 6 and 8 are nearly adultlike although the variation is still larger than in adults
(Figure 3-6). This indicates that anticipatory scaling
of forces occurs in conjunction with maturation of
coordinated movement (Forssberg et al., 1992).
80
Acceleration (N/s2)
200
800
0
2
1-
2-
4-
6-
t
5
11
ul
-1
8Ad
11
Age (yrs)
sp
si
250
200
Percent
objects. This suggests that the associative transformation between the objects size and weight involves
additional demands of cortical processes, requiring further cognitive development. In children 3 to 7 years of
age the difference between large and small objects is
greater than in adults. Older children seem capable of
reducing the effect if it is not purposeful for manipulation, whereas younger children still strongly rely on
visual information (Gordon et al., 1992).
150
100
50
FRICTION
Tactile influence on the force coordination is available
on touching an object, contrary to weight influence,
which is not available until lift-off. Tactile information
from fingertips triggers prestructured motor commands based on sensorimotor memories and adjusts
the force coordination based on the friction of the
contact surface. The employed grip forces are different
when one holds a slippery bottle than when holding a
tool covered with rubber, even if they have the same
weight. When contact pads on the test object are
altered by exchangeable contact surfaces of silk and
sandpaper, the relationship between grip force and load
force is changed before lift-off. In adults there is an
initial adjustment to the new frictional condition
during the first 0.1 second and secondary adjustments
during the loading and static phases (Johansson &
Westling, 1987). These adjustments are important in
establishing an adequate safety margin, which prevents
one from dropping the object. The ratio between grip
and load force actually used, minus the slip ratio
necessary to prevent the object slipping out of the
hand, makes up the safety margin.
One-year-old children have a larger safety margin
than adults. Gradually, the safety margin decreases in
conjunction with increased coordination and less
variability during the first 5 years (Figure 3-7). Some
children of 18 months can scale the grip force based on
tactile information in the beginning of the lift. They
have a higher grip force for slippery materials than for
rough ones during consecutive lifts with the same
friction. Several years are necessary before children can
handle objects with different frictional surfaces in the
same elegant way as adults. Children younger than 6
years of age, sometimes up to 10 or 12 years, need
several lifts and a predictable order to adjust the grip
force to the current friction and form an internal
representation before setting the parameters of the
programmed motor output. The difference between
adaptation to weight and adaptation to friction is that
frictional conditions appear directly upon touching
the object, whereas weight information is likely more
crucial for anticipatory control because the weight is
not available until lift-off. Grip forces of high amplitude
1-
2-
3-
4-
5-
5
10
-1
611
ul
Ad
Age (yrs)
ORGANIZATION OF
SENSORIMOTOR CONTROL
These studies have enhanced our knowledge of the
mechanisms underlying sensorimotor integration and
anticipatory control in a grasping task. The model
implies that for this manipulatory act visual, tactile, and
proprioceptive information are integrated with memories of similar objects from previous manipulative experience. The appropriate muscles are then activated in
the proper sequence based on the internal memory
representation of the object, resulting in a well timed
and coordinated grasping and lifting act. The act
includes selection of motor programs that control orientation of the hand and the subsequent limb trajectories. These programs may be stored in sensorimotor
(procedural or implicit) memory and used in an unconscious way, different from declarative (explicit) memory
that is used in conscious recall of facts, events, and
percepts (Squire, 1986) (see Chapter 6). The existence
of sensorimotor memory has been demonstrated by
disorders in higher brain function. It seems that networks involving cortical function, especially posterior
parietal cortex, are important for anticipation. Jeannerod
54
FORCE COORDINATION
When making a lift, the temporal pattern is rarely
impaired in children with ADHD regardless of whether
or not the ADHD is accompanied by DCD (Pereira
et al., 2000); for children with CP, it is almost always
disturbed to some degree. In these children the difference in the time at which the first finger or thumb
makes contact with the object and the time at which
the second finger makes contact is larger than in typically developing children, indicating disturbed coordination of finger movement and shaping of the fingers
toward the size of the object, although there is a great
deal of variation within the group, from almost as good
56
T1
CP
T0
T2T3
T1
T2 T3
6N
F4
F6
F4
F3
F5
F6
30 N/S
F3
Load force
4N
Position
F2
F2
60 mm
50 mm/s
Velocity
Acceleration
F1
F1
2 mm/s2
1 sec
Figure 3-8 Grip force from the index finger (ind) and thumb (th), grip force rate, load force, load force rate, vertical
position, velocity, and acceleration as a function of time for representative trials during object replacement and release for
one child in the control group and one child with hemiplegia. The grip and load force rates are shown using a 20 point
numerical differentiation. Vertical lines indicate the initiation of vertical displacement (T0), object contact with the table
(T1), release of one digit (T2) and then the opposing digit (T3). The measured force parameters are shown by arrows
indicating peak velocity (F1), peak load force rate corresponding to table contact (F2), minimum grip force rate (F3), grip
force at replacement (F4), grip force at table contact (F5), and grip force at load force zero (F6) (dashed line in the right
traces). (Modified from Eliasson AC, Gordon AM [2000]. Impaired force coordination during object release in children with
hemiplegic cerebral palsy. Developmental Medicine in Child Neurology, 42:228234.)
58
80
60
40
20
0
Normal
Impaired
Sensibility
SUMMARY
Motor controlmeaning how the CNS controls movementis complex, but by understanding the principles
of how movements are organized, it is possible to use
the knowledge that has been gained to plan intervention. By using this perspective we can help children
to learn more about themselves and help them find
more efficient ways to use their possibilities rather than
focusing on the impaired or odd movement. An important perspective to put across is that there is nothing
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Eliasson AC (2005). Improving the use of the hands in
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Eliasson AC, Gordon AM, Forssberg H (1992). Impaired
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Eliasson AC, Gordon AM, Forssberg H (1995). Tactile
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60
Chapter
CHAPTER OUTLINE
DEVELOPMENT OF HAPTIC PERCEPTION
Haptic Perception in Infants
Haptic Perception in Children
Gender and Hand Differences in Haptic Recognition
and Haptic Accuracy
Summary and Implications for Practice
FUNCTIONS CONTRIBUTING TO HAPTIC
PERCEPTION
Role of Somatosensory Sensation in Haptic
Perception
Role of Manual Manipulation and Exploratory
Strategies in Haptic Perception
Role of Vision and Cognition in Haptic Perception
Summary and Implications for Practice
EVALUATION OF HAPTIC PERCEPTION IN INFANTS
AND CHILDREN
HAPTIC PERCEPTION IN CHILDREN WITH
DISORDERS
Prematurity
Mental Retardation
Brain Injury
Learning Disabilities and Related Disorders
Summary and Implications for Practice
SUMMARY
The hand has two closely related functions: It is both an
executive and a perceptual organ (Bushnell & Boudreau,
1998; Gibson, 1988; Hatwell, Streri, & Gentaz, 2003;
Lederman & Klatzky, 1998). As an executive organ it is
63
64
DEVELOPMENT OF HAPTIC
PERCEPTION
HAPTIC PERCEPTION IN I NFANTS
In the infant the hands and mouth are both potential
sources of haptic information. The mouth can be used
to gain information about the shape and substance of
They also noted that the infants held the objects for
relatively long periods, as much as ve times as long as
they would have been expected to visually attend to an
object. Because these 4-month-old infants were so
competent at identifying objects tactually and visually,
Streri and colleagues (Streri, 2003a; Streri & Spelke,
1988) questioned Piagets theory that vision and touch
become integrated through haptic exploration of
objects and suggested that this ability may be present
without substantial experience in handling objects. In a
recent study of cross-modal recognition in newborns,
Streri and Gentaz (2004) have even suggested that
under some limited conditions, newborns have the
ability to extract shape in a tactile format and transfer it
to a visual format, independent of common experience.
Molina and Jouen (1998, 2001, 2003) also reported
that newborns can discriminate between rough and soft
textures and modify their grasping according to the
texture of the grasped object.
surfaces containing one or two holes or having openings or closings on their outer edges. These authors
found that the ability of children to identify objects and
shapes by touch progressively improved with increased
age. Children 212 to 312 years of age were able to
correctly recognize common objects but were unable
to identify shapes. By 312 to 5 years of age children
developed the ability to match topologic forms.
Recognition of geometric gures emerged at 4 to 412
years with the ability to differentiate curvilinear (circle
and ellipse) from rectilinear (square and rectangle)
shapes. The ability to recognize geometric gures in
greater numbers and levels of complexity was shown to
progressively improve from 412 to 7 years of age.
Benton and Schultz (1949) also studied intermodal
(haptic-visual) matching of common objects in a group
of 156 3- to 5-year-old children and found that performance progressively improved with age. Three-yearold children typically were able to recognize 50% of the
items presented (mean 4.0 out of eight items). Fouryear-old children performed only slightly better than
children in the 3-year-old age group (mean = 4.5).
Near-perfect performance typically was found by 5 years
of age, with most children correctly recognizing at least
seven of the eight objects presented.
Hoop (1971a) also studied intermodal (hapticvisual) matching at 312 to 512 years. Like Piaget and
Inhelder, Hoop found the identication of common
objects to be easier than the recognition of topologic
forms and geometric gures. There was little variation
in the ability of 312- to 512-year-old children to match
topologic forms (means ranging from 2.3 to 2.6 out of
a maximum score of 4). Miller (1971) reported a
similar nding. The 3- and 4-year-old children in her
study were able to identify fewer than half of the
intermodally (haptic-visual matching) and intramodally
(haptic-haptic matching) presented shapes. Like Piaget
and Inhelder, Hoop found the recognition of topologic
forms through intermodal (haptic-visual) matching to
be easier than the identication of geometric gures.
However, this has not been a consistent nding
(Derevensky, 1979). Derevensky (1979) suggested that
listing shapes as topologic or geometric may be an
incorrect method of categorization, and suggested that
it may not be whether a shape is topologic or geometric
but the nature of the distinctive features that it contains
that contributes to task difculty.
Another interesting nding was reported by
Abravanel (1972), who noted that, in a series of intermodal (haptic-visual matching conditions, it was easier
for 6- to 8-year-old children to identify solid (threedimensional) than flat (two-dimensional) geometric
gures. She attributed this to possible variation in the
usefulness of the manipulation strategies used by the
children in shape exploration. This topic is discussed in
depth in a later section of this chapter.
66
68
FUNCTIONS CONTRIBUTING TO
HAPTIC PERCEPTION
Most haptic perception tasks are complex. Research
suggests that various factors contribute to haptic perception, including somatosensory processing, manual
and in-hand manipulation, and vision and cognition.
70
Table 4-1
Object Dimension
Exploratory Procedure
SUBSTANCE
Texture
Hardness
Temperature
Weight
Lateral motion
Pressure
Static contact
Unsupported holding
STRUCTURE
Weight
Volume
Global shape
Exact shape
Unsupported holding
Enclosure; contour following
Enclosure
Contour following
FUNCTION
Part motion
Specic function
BOX 4-1
72
Grasping
Banging
Fingering
Mouthing
Switching (hand to hand)
Squeezing
Rubbing
Pressing
Poking
Slapping
Scooting
Dropping
Table 4-2
Age Range
Haptic Strategy
212 to 4 years
4 to 5 years
5 to 6 years
6 to 7 years
74
Examples of Manipulation
Strategies
If children want:
To compare two objects for texture, they use a lateral
motion, often with the index nger.
To compare hardness, they use pressure.
To examine temperature, they use static contact.
To examine volume of three-dimensional objects,
they tend to embrace the object.
To compare weight, they tend to hold the object in
their hand and lift it from the surface.
Hatwell Y (2003). Manual exploratory procedures in
children. In Y Hatwell, A Streri, E Gentaz (editors):
Touching for knowing (pp. 6782). Philadelphia, John
Benjamins Publishing; Klatzky RL, Lederman SJ (2003).
The haptic identication of everyday life objects. In Y
Hatwell, A Streri, E Gentaz (editors): Touching for
knowing (pp. 105122). Philadelphia, John Benjamins
Publishing; Klatzky RL, Lederman SJ, Metzger VA
(1985). Identifying objects by touch: An expert system.
Perception and Psychophysics, 37:299302; Streri AF
(2003a). Manual exploration and haptic perception in
infants. In Y Hatwell, AF Streri, E Gentaz (editors):
Touching for knowing (pp. 5166). Philadelphia, John
Benjamins.
Cognition
The development of infants and young childrens
exploration of the environment is linked to their understanding and knowledge about the world (Bushnell &
Boudreau, 1998; McLinden & McCall, 2002). Because
cognition and vision are closely linked in haptic object
identication, it is difcult to categorize certain functions, such as mental imagery, that involve both cognition and vision. The ability to use cognitive strategies
(mental imagery and verbalization) to aid in haptic
object recognition develops during childhood. Piaget
and Inhelder (1948/1967) considered the ability to
distinguish objects through the use of touch to be an
external reflection of ones capacity to transform tactile
properties of objects into visual images (integrate visual
and haptic information), although recently this view
has been questioned. This ability to use visual imagery
to improve haptic recognition and memory of objects
is thought to contribute to childrens ability to recognize objects on tests of haptic perception and reproduce objects through drawing. In fact, research has
shown that adults with high spatial ability and skill in
76
EVALUATION OF HAPTIC
PERCEPTION IN INFANTS AND
CHILDREN
Assessment of haptic perception can be considered
from the perspective of standardized versus nonstandardized assessments and also analyzed according to
product/process dimensions. Most of the standardized
assessments examine the product; that is, the accuracy
of haptic perception, and the number of items the child
passed. Many of the nonstandardized assessments used
primarily for research purposes examine the process, or
the way the child approaches a task, and the effect of
the nature of the task on haptic style or strategy.
There are several standardized assessments to
evaluate accuracy of haptic perception The Miller
Assessment for Preschoolers (Miller, 1988) includes a
stereognosis item that uses common objects for the
younger (2- to 4-year-old) children and geometric
shape matching for older (3- to 5-year-old) children.
Although a specic score is not given for this item,
percentile equivalents can be determined from the
score sheet.
The Sensory Integration and Praxis Tests (SIPT)
(Ayres, 1989) make up a 17-test battery that assesses
aspects of sensory processing (visual, tactile, vestibularproprioceptive) and praxis. They are standardized on
children ages 4.0 to 8.11 years. This battery includes
several tests that tap aspects of haptic abilities. The
Manual Form Perception (MFP) test, which assesses
stereognosis, has two components. The rst component is a haptic-visual intermodal matching task in
78
HAPTIC PERCEPTION IN
CHILDREN WITH DISORDERS
PREMATURITY
The characteristics of touch most fully explored in the
infant are those related to social and emotional functioning, and research on the perceptual role of touch
often proceeds separately from research on its social
role (Rose, 1990). Recently the specic role of tactile
stimulation has been examined, and numerous studies
have investigated whether the preterm infant will benet from changes in the quantity, quality, or patterning
of stimulation in the environment (Field, 2002, 2003).
The sensory organization and perceptual processing
characteristics of the preterm infant also have been
investigated. Rose and co-workers (Rose, Schmidt, &
Bridger, 1976; Rose et al., 1980) examined the infants
responsivity to (passive) tactile stimulation and their
abilities to discriminate different intensities of such
stimulation. Infants were assessed at 40 weeks gestational age, and, while sleeping, they were touched with
plastic laments of different intensities and their cardiac
and behavioral responses were examined. Results indicated that preterm infants are signicantly less responsive to tactile stimulation than are full-term infants.
Rose, Gottfried, and Bridger (1978) also examined
differences between preterm and full-term infants at 1
year of age in an active touch multimodal (haptic and
visual) task using a habituation paradigm. Preterm
infants did not show any evidence of cross-modal
transfer, whereas full-term infants did show such
transfer. These results indicate that full-term infants are
80
M ENTAL RETARDATION
Research conducted with individuals with mental
retardation provides insight into the relationship
between haptic perception and cognitive ability. Much
of the research examining the relationship among
cognitive abilities and haptic manipulation and motor
skill has been done with children with Down syndrome
(e.g., Brandt, 1996; Moss & Hogg, 1981). These
studies generally reported that children with Down
syndrome did not show as effective accommodation of
their hands to objects after grasp and did not use haptic
manipulation and exploratory strategies as readily as
typical children. However, it is difcult to directly
attribute these results to the childs cognitive abilities
because many of these ndings can be attributed to the
sensorimotor problems or other aspects of Down
syndrome (Exner, 1991). For example, Brandt and
Rosen (1995) found that children with Down syndrome demonstrated impaired peripheral somatosensory function (sensory nerve conduction velocities)
and suggested that this may contribute to poor tactual
perceptual performance. It is likely that, regardless of
the cause of the delay, impairment in the ability to
efciently explore objects interferes with learning about
key object properties (Exner, 1991).
Jones and Robinson (1973) compared the performance of a group of children with mental retardation (mean IQ = 47) to an age-matched group
of children with normal intelligence. Accuracy of
intramodal (haptic-haptic) and intermodal (hapticvisual) discrimination of meaningless shapes was poorer
for the children with mental retardation than for the
children with average intelligence. However, other
studies found that when children with mental retardation and typical children were matched for mental
age, the between-group difference in accuracy of haptic
recognition disappeared (Derevensky, 1976, cited in
Derevensky, 1979; Jones & Robinson, 1973; Medinnus
& Johnson, 1966). In fact, two studies identied subjects with mental retardation as performing better than
normal mental age-matched controls in intramodal
(haptic-haptic) and intermodal (haptic-visual) matching tasks (Hermelin & OConnor, 1961; Mackay &
Macmillan, 1968).
Because matching subjects for mental age eliminated
differences in haptic accuracy scores between children
with mental retardation and typical children, it can be
concluded that some aspects of higher cognitive processing are most likely necessary for task completion. In
addition to verbal intelligence, haptic strategies have
BRAIN I NJURY
Impairments in tactile perception frequently have been
reported in children with a diagnosis such as cerebral
palsy that indicates a known brain injury (Bolanos et
al., 1989; Boll & Reitan, 1972; Cooper et al., 1995;
Duque et al., 2003; Krumlinde-Sundholm & Eliasson,
2002; Reitan, 1971; Solomons, 1957; Tachdjian &
Minear, 1958; Van Heest, House, & Putnam, 1993;
Yekutiel, Jariwala, & Stretch, 1994) and with traumatic
brain injury (Ayres, 1989). Stereognosis (haptic
identication of shapes or common objects) is often
cited among the tactile functions showing impairment.
Intermodal (visual-haptic) matching of shapes also
has been shown to be impaired in children with brain
injury (Birch & Lefford, 1964). Solomons (1957)
found that children with brain injury were also
impaired in the haptic discrimination of size and
texture, although they did not differ from typical
children in their ability to haptically match objects by
weight. Although Boll and Reitan (1972) cited no
problems in haptic shape recognition, they noted that
the children with brain injury performed poorly on a
complex tactile performance task that required shape
recognition for task completion. Rudel and Teuber
(1971) compared the ability of typical children and
children with brain injury to discriminate three-
82
SUMMARY
Haptic perception in infants and children has been
reviewed in depth in this chapter. It was the authors
intent to provide an overview of the literature on the
topic, with emphasis on material relevant to the
evaluation and treatment of disorders in haptic
perception in children with suspected and identied
CNS dysfunction. The literature reviewed provides
insight into the development of haptic perception and
the identication of factors that may be contributing to
impairment in haptic perception in some children.
Haptic perception emerges in early infancy and continues to mature into adolescence. The infant initially
uses oral exploration to learn about objects. The hands
rst transport objects to the mouth and later become a
primary tool for haptic object exploration. Manual
manipulation of objects begins with grasping and is
later replaced by more specic manipulation patterns
(e.g., ngering, banging) that are tailored to the
physical properties of the object. Manual manipulation
gradually replaces mouthing as the preferred method of
object exploration. This is followed by a long period of
development in which the accuracy of haptic object
recognition improves and the complexity of manual
manipulation and exploratory strategies increases.
The accuracy of haptic object recognition is related
to the choice of haptic manual manipulation and
exploratory strategies. Vision appears to guide the
development of manual manipulation and helps to
bring meaning to the haptic information being
retrieved by the hands. It is not until 6 years of age that
children can easily explore objects with the hands
without the assistance of vision. With time the hands
develop the ability to retrieve information from the
environment without the aid of vision, making it
possible for vision and haptic sensory processing to take
REFERENCES
Abravanel E (1968a). Intersensory integration of spatial
position during early childhood. Perceptual and Motor
Skills, 26:251256.
Abravanel E (1968b). The development of intersensory
patterning with regard to selected spatial dimensions.
Monographs of the Society for Research in Child
Development, 33(2):153.
Abravanel E (1970). Choice for shape vs. textural matching
by young children. Perceptual and Motor Skills,
31:527533.
Abravanel E (1972). How children combine vision and
touch when perceiving the shape of objects. Perception
and Psychophysics, 12(2A):171175.
84
86
88
Chapter
CHAPTER OUTLINE
MATURE REACHING MOVEMENTS
Movement Speed
Transport and Grasp Phase
Role of Vision
Role of Proprioception
Integration of Sensory Information
Movement Planning
MOVEMENT SPEED
If the velocity of the hand during a reaching movement
is plotted versus time as in Figure 5-1, one can see that
the tangential velocity curve is bell shaped. The
reaching movement is continuous with one single peak
of velocity. In the last part of the reaching movement,
when the hand is close to the target, the velocity is
slow. This typical bell-shaped velocity curve is seen
when the reach is carried on with, as well as without,
visual feedback (Jeannerod, 1984; Morosso, 1981).
This indicates that the reaching movement is programmed in advance of movement onset to a high
degree.
89
90
cm/s2
cm/s
1500
750
70
0
750
0
0
200
400
600
ms
Figure 5-1 Kinematic proles of the transport
component of a reaching movement. The heavy line
depicts the velocity of the wrist (cm) as a function of
time. This curve describes a single continuous movement
with a single peak of velocity. The two peaks connected
by the thin line depict the acceleration of the wrist (cm2)
as a function of time. The positive peak constitutes one
phase of acceleration and the negative peak one phase
of deceleration, together forming one movement unit.
(From Jeannerod M, et al. [1992]. Parallel visuomotor
processing in human prehension movements. In R Caminiti,
PB Johnson, Y Burnod [editors]: Control of arm movement in
space. New York, Springer-Verlag.)
ROLE OF VISION
It is obvious that vision plays a very important role in
our ability to reach out for objects. One need only
imagine what it would be like to be blind to realize the
importance of vision to reaching. Vision is the sense
that provides us with information about the layout of
the environment, and when reaching for an object,
vision denes both the position and shape of the object.
Seeing the environment gives us an opportunity to
anticipate upcoming events and plan our movements in
an anticipatory fashion. One example of this is the way
we shape our hand before contact with an object. A
blind person reaching for an object does not have this
ability but has to touch the object rst and then,
guided by haptic information, shape the hand for grasp.
If we cannot foresee upcoming events and plan our
movements ahead of time, our movements will be
uncoordinated of necessity.
Given that visual information is important both for
movement planning and execution, one may ask what
should be seen and when during the movement we
need that information. The answer to this seems to be
that full visual information is optimal. Several studies
show that we must be able to see the target both before
and during a movement or movement quality is reduced
(Berthier et al., 1996; Sarlegna et al., 2003). Moreover,
if we can see our hand as we move it toward the target,
movement accuracy and efciency will be improved
(Connolly & Goodale, 1999; Sarlegna et al., 2004;
Saunders & Knill, 2003; Schenk, Mair, & Zihl, 2004).
The minimum delay needed for visual information
to affect the physical movement of the hand traditionally has been thought to be around 200 msec (Keele &
Posner, 1968). Because many naturally occurring
reaching movements take around 500 msec to com-
ROLE OF PROPRIOCEPTION
We have receptors in our muscles, tendons, joints, and
skin that provide us with information about the
positions and movements of our body parts. This is
here termed proprioception, after Sherrington (1906).
Although it is relatively easy to nd out how we can
move without vision or with degraded vision, proprioceptive information cannot be manipulated as easily.
Instead, the research on the role of proprioception has
focused on animal experiments and patients with sensory loss caused by diseases.
One line of research has used deafferented monkeys.
When their dorsal spinal roots are sectioned, the
monkeys are deprived of sensation from the upper
limbs but the motor nerves are unaffected. This technique was used in early experiments by Mott and
Sherrington (1895). They reported that the monkeys
limbs became useless after such operations and that the
animals used their upper limbs only if forced to and
then in an awkward way. They concluded that afferent
information from the limbs was necessary for both
movement initiation and control. Similar results also
were reported by Lassek & Moyer (1953). However,
later experiments with deafferented monkeys reported
different results. Taub and Berman (1968) reported a
clear improvement in motor function after the initial
disability that resulted from the section of the nerves.
The animals were able to reach for and grasp objects
with a primitive pincer grip a few months after surgery.
Recovery of function also has been reported by Knapp
and co-workers (1963). Bossom and Ommaya (1968)
have pointed out that motor pathways can be damaged
easily during a rhizotomy and that this could be why the
degree of recovery of function varied between studies.
92
DEVELOPMENT OF REACHING
DURING INFANCY
BEGINNING TO MASTER THE REACH
Observing a newborn babys arm movements, one might
perceive them as random, performed without meaning.
However, even at birth the infant is capable of movements that require some degree of sensory motor integration. Von Hofsten (1982) placed 5-day-old infants
in a semireclining seat that gave good support to the
trunk and head but allowed free movement of the
arms. The infants were presented with a colorful tuft
that moved irregularly and slowly in front of them. The
infants arm movements were recorded with two video
cameras, making it possible to calculate the arm trajectory in three-dimensional space. All infants noticed the
tuft and were able to follow it with eye and head
movements for varying periods. The infants forward
extended arm movements, as well as looking behavior,
were analyzed. When the infants were xating the tuft,
they aimed their reaching movements closer to it than
when looking in another direction or closing their eyes.
Thus a child only a few days old already has a rudimentary visual control of arm movements. Moreover,
when initiating an aimed movement toward a visually
xated target, the infant must know where its arm is.
midline. Older infants often display an asymmetric onehand reach. He reported that when infants rst attained
the ability to sit without support they shifted toward
reaching more with one hand so that the other could
be used to maintain balance. Hopkins and Rnnqvist
(2002) studied reaching behavior in infants aged about
6 months who were not yet able to sit without support.
They compared the quality of the reaching movements
when the infants were provided with rm postural
support and when they were sitting in a commercially
available chair. That the rm postural support resulted
in a decrease in the number of movement units
indicates that this extra support improved the reaching
behavior. Clinical observations made by Grenier
(1981) also indicate that postural control is important
for coordinated arm movements and that if infants are
supported appropriately at the neck and trunk they can
perform coordinated arm movements at a much earlier
age than is typical.
Postural control does not only act by maintaining
balance after it has been perturbed. We also have the
ability to anticipate an upcoming situation that will
perturb our balance and prepare ourselves by means of
postural adjustments. There is some evidence that this
anticipatory mode of counteracting upcoming forces
on the body starts to operate during the rst year of
life. Von Hofsten and Woollacott (1989) showed that
at 10 months of age children activated the muscles of
the trunk before making voluntary arm movements.
The integration between posture and voluntary control
is an important prerequisite for coordinated arm and
hand movements. Little is known of how children with
motor impairments can integrate voluntary movements
and posture, but it is possible that this is one contributory factor in these childrens ne motor
disturbances.
MOVEMENT PLANNING
As discussed, the reaching movement can be analyzed
in terms of acceleration and deceleration. A phase of
acceleration followed by a phase of deceleration then
constitutes a movement unit. When the infants rst
start to reach and grasp, at around 4 months of age, the
ability to plan the movement ahead of time is still poor.
As a consequence of this, the movement path is awkward and crooked, and the trajectory consists of many
movement units. This changes after the infant has
practiced reaching for some time, and at around 1 year
of age the number of movement units has decreased
and the movement paths are straighter (Konczak &
Dichgans, 1997; von Hofsten, 1991) (Figure 5-2).
The ability to plan movements ahead of time, and
not only react to what has already happened, is fundamental for movement skill. One example when this is
94
9 months
Vertical
05:58:51
Start
Horizontal
15 months
24 months
Adult
05:58:31
10 cm
Start
05:58:11
05:57:91
Figure 5-3 Two views of the performance of a wellaimed reach by an infant who is 21 weeks of age. The
frame on the bottom is the start of the reach. The interval
between frames is 0.2 sec (digital clock reading in the
upper portion of each frame). The child is directing the
reach ahead of the object to the point at which the
object will be at the end of the reaching movement.
(From von Hofsten C [1980]. Predictive reaching for moving
objects by human infants. Journal of Experimental Child
Psychology, 30:369382.)
MOVEMENT-TO-MOVEMENT VARIABILITY
The infant has not yet learned the most efcient way
of performing a movement and is still exploring the
possibilities of its own body. Therefore he or she will
perform a specic task, such as reaching for a toy, with
signicant movement-to-movement variability. In fact,
being able to perform a specic task in a consistent
manner is a prominent feature of movement skill.
Figure 5-4, A shows the superimposed movement
trajectories of a 1-year-old girl reaching for an object.
In Figure 5-4, B the same task is performed by an 11year-old boy. Although the little girl grasps the object
without difculty, it is clear that she does not reach for
the object with the same skill as the older boy does.
Lhuisset and Proteau (2004), who studied reaching
movements in children 6, 8, and 10 years old, found
that although the children clearly planned the movements ahead of time, the planning processes were still
more variable than for adults.
500
500
400
Vel (mm/sec)
Vel (mm/sec)
400
300
200
0
0
200
100
100
300
0.2
0.4
0.6
(sec)
0.8
0
0
0.2
0.4
0.6
0.8
(sec)
Figure 5-4 The gures show that a young child performs a specic movement with high variability, whereas an older
child has a more consistent movement pattern. A, Trajectory of the hand for a 12-month-old girl who is reaching
repeatedly for the same object. B, How an 11-year-old boy performs the same movement. (From Eliasson AC, Rsblad B
[2001]. Arm och handrrelser: Normal och avvikande utveckling. In E Beckung, E Brogren, B Rsblad [editors]: Sjukgymnastik fr
barn och ungdom. Teori och tillmpning. Lund, Studentlitteratur.)
96
MOVEMENT PLANNING
A common nding in motor control research on
children with motor impairments is that the ability for
movement planning is impaired. One example of how
the ability to plan reaching movements can be impaired
comes from a study on reaching in children with
attention decit hyperactivity disorder (ADHD)
(Eliasson, Rsblad, & Forssberg, 2004). To analyze the
kinematics of the arm movement we used a digitizing
tablet. The task for the children was to move a cursor
on a computer screen with a hand-held digitizer on the
tablet. Start and target positions on the screen were
always visible during the movement. The screen cursor,
however, could either be visible throughout the entire
movement or blanked at movement initiation. Analysis
showed that movement control was impaired in
children with ADHD and that their problems were
especially pronounced when the screen cursor was not
visible on the screen. Because the children could not
visually correct the movement when the screen cursor
was blanked, results indicate a poorer motor programming in children with ADHD. Moreover, the
children with ADHD performed jerky movements with
higher peak accelerations than the control group of
children. As discussed earlier in this chapter, the choice
of movement speed is crucial for how skillfully we
manage to reach for and grasp an object. The children
with ADHD adopted higher movement speed compared with the typically developed children but this
high speed was counterproductive and resulted in
increased movement endpoint errors and further
corrective movements.
Similar results also have been found when the control of reaching movements in children with developmental coordination disorder (DCD) has been studied.
Van der Meulen and colleagues (1991a,b) tested the
ability in children with DCD to make precise arm
movements. In a rst study, the task for the child was
to reach for a target as quickly and precisely as possible.
In a second study, the ability to track a target that
moved unpredictably was assessed. In both studies, the
children were tested in situations in which they did or
REFERENCES
Alstermark B, Gorska T, Lundberg A, Petterson L-O
(1990). Integration in descending motor pathways
controlling the forelimb in the cat. 16. Visually guided
switching of target-reaching. Experimental Brain
Research, 80:111.
Bernstein N (1967). The coordination and regulation of
movement. London, Pergamon Press.
Berthier NE, Clifton RK, Gullapalli V, McCall DD, Robin D
(1996). Visual information and object size in the control of
reaching. Journal of Motor Behavior, 28:187197.
Berthier NE, Clifton RK, McCall DD, Robin DJ (1999).
Proximo distale structure of early reaching in human
infants. Experimental Brain Research, 127:259269.
Bossom I (1974). Movement without proprioception.
Brain Research, 45:285296.
Bossom I, Ommaya AK (1968). Visuomotor adaptation to
prismatic transformation of the retinal image in monkeys
with bilateral dorsal rhizotomy. Brain, 91:161172.
Brooks VB (1976). Some examples of programmed limb
movements. Brain Research, 71:3847.
Claxton LJ, Keen R, McCarty ME (2003). Evidence of
motor planning in infant reaching behavior. Psychological
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Clifton R, Rochat P, Robin DJ, Berthier NE (1994).
Multimodal perception in the control of infant reaching.
Journal of Experimental Psychology: Human Perception
and Performance, 20:876886.
Connolly JD, Goodale MA (1999). The role of visual
feedback of hand position in the control of manual
prehension. Experimental Brain Research, 125:281286.
Eliasson A-C, Rosblad B, Forssberg H (2004). Disturbances
in programming goal-directed arm movements in children
with ADHD. Developmental Medicine in Child Neurology,
46:1927.
Fitts PM (1954). The information capacity of the human
motor system in controlling the amplitude of movement.
Journal of Experimental Psychology, 47:381391.
Gesell A, Ames LB (1947). The development of
handedness. Journal of Genetic Psychology, 70:155175.
98
Chapter
CHAPTER OUTLINE
CASE SCENARIO
MOTOR SKILLS ARE ADAPTIVE
What Is the Overall Framework for Understanding
Movements?
INTRODUCTION TO COGNITIVE CONTRIBUTIONS TO
MOTOR SKILLS
COGNITIVE PROCESSES IN MOTOR SKILLS
Attention
Perception
Concept Formation (Knowledge)
Memory
SKILL ACQUISITION (LEARNING)
EPILOGUE: RELATIONSHIP BETWEEN COGNITIVE
AND MOTOR DEVELOPMENT
SUMMARY
CASE SCENARIO
Consider this simple scenario. Jimmy, a 2-year-old
typically developing child, is sitting at a table, reaching
out to grasp a glass full of water so as to bring it toward
his mouth. This simple functional act, one that is
carried out by children with seemingly effortless ease,
nevertheless is extremely complicated and poses several
challenges to a developing system such as Jimmys. This
101
102
INTRODUCTION TO COGNITIVE
CONTRIBUTIONS TO MOTOR
SKILLS
The importance of cognition in motor skill acquisition
and development is well established. However, the
reverse also has been proposed: that perceptual motor
activity is a mechanism for cognitive development.
However, the importance of cognition to motor skills
depends on the theoretical orientation that is used.
COGNITIVE PROCESSES IN
MOTOR SKILLS
In this section, we discuss a few important components
of cognition critical to the successful generation of
motor skills. Attention, perception, concept formation,
memory, and learning are briefly discussed. Although
each component is discussed separately for clarity, one
should understand that in the development of motor
skills, many of these components interact with each
104
other and may assume differential importance depending on the demands of the task.
ATTENTION
Attention is a fundamental aspect of all human activity.
We are able to perceive stimuli and act on them better
when we attend to the stimulus of interest and ignore
extraneous stimuli. Our sensory systems receive a
tremendous amount of information. If we did not have
a mechanism to lter unwanted stimuli, we would
encounter sensory overload. At any given moment, we
are aware of only a few stimuli that are functionally
important to the task at hand, and our awareness is
limited by our capacity for processing information.
Thus functional attention is selective by denition.
Attention can be dened by examining its constituent parts of arousal, capacity, and selectivity (Plude,
Enns, & Brodeur, 1994). Arousal refers to the momentary level of excitation in the information processing
system that helps tune our cognitive systems to
optimally receive information. Capacity refers to the
actual capacity of our information processing system. It
is generally accepted that humans can process a certain
amount of information at any given moment. Finally,
selectivity refers to the ability of the system to allocate
resources so as to focus on certain stimuli and not
others.
Selective attention is a multidimensional process,
involving components of orienting, ltering, searching
and expecting (Plude et al., 1994). From an early age,
infants show preference for orienting their vision to
attend to certain stimuli while ignoring others (Maurer
& Lewis, 1991). In fact, neonates spend more time
attending to their mothers face than the faces of
strangers, even when other sensory cues, such as smell
and auditory cues, are excluded (Bushnell, Sai, &
Mullin, 1989). The orienting response is variable and
not developed early in life, presumably because the
neural structures that control such behavior (e.g., the
superior colliculus) are not fully developed. Nevertheless, the evidence suggests that infants demonstrate
beginning capabilities for selective orientation to
preferred stimuli.
Another aspect of selective attention is that infants
show a preference for novel stimuli rather than stimuli
that have been present in the environment. Most of us
have observed infants paying more attention to new
faces in comparison with familiar faces. This phenomenon is known as habituation and refers to the decrease
in the amount of visual attention (time spent on a
stimulus) devoted to more familiar stimuli (Bertenthal,
1996; Ruff, 1986). Ruff found that the amount of time
spent in examining novel stimuli decreases as the infant
becomes familiar with an object and suggests that the
PERCEPTION
Perceptual processes constitute an important part of
cognitive contributions to motor skills. Perception can
be dened as a process of collecting information from
the environment based on vision, touch, hearing, and
muscle and joint proprioceptors to construct an
internal representation of space and the body (Kandel,
2000). Thus our perception is created through an
active process of searching for and attending to stimuli
based on our sensory organs. All pertinent information
is then used in the construction of an internal
representation.
Historically, perception was thought to emerge from
a developmental process as infants and young children
developed their repertoire of sensorimotor behaviors
(Piaget, 1952). The current view, however, challenges
this notion and proposes that different sensory inputs
converge into a unied representation that precedes
thought and action (Marr, 1982). The emerging
framework from the cognitive neurosciences proposes
that there may be at least two independent and parallel
perceptual processes: one that is used in the recognition of objects and the other used for the guidance of
movements (Goodale et al., 1994). Thus visual information about an object in the environment is processed
by separate neural pathways and used for different
purposes (Bertenthal, 1996; Goodale & Westwood,
2004). The system for the identication of objects, also
called the ventral stream, is proposed to project from
the visual cortex to the temporal lobe. The system for
Perceptual-Motor Processes
We must perceive in order to move, but we must also
move in order to perceive.
(Gibson, 1979)
This statement, from one of the most influential
psychologists in the area of perception, highlights the
reciprocal relationship between perception and action.
According to Gibson (1979) perceptual systems have
adapted to use information pertinent to actions that
are readily available in the environment. For instance,
perceptual-motor systems use visual information available in the optic array, haptic information from hands
as they explore objects, and proprioceptive information
available from muscles and joints. Although movements are adapted in response to perceptual processes,
the reverse is true as well. Such reciprocity was shown
in a study that tested crawling infants and recently
walking infants on their locomotion on two different
surfaces; a rigid and a pliable surface. Although crawling
infants did not differentiate between these two surfaces, recently walking infants changed their mode of
locomotion depending on the surface. They crawled on
the pliable surface and walked on the rigid one (Gibson
et al., 1987). More recently, it was shown that recently
walking infants adopt a more stable posture (sitting) as
they negotiate a surface with a downward incline,
whereas crawling infants did not adapt their posture
(Adolph, Eppler, & Gibson, 1993). These studies show
that perception (e.g., perceived stability of surface)
106
influences action and action in turn influences perception (e.g., newly walking infants differentiating among
surfaces).
Contrary to the proposals of early models of
perceptual-motor development (Piaget, 1952), goaldirected behavior is observed very early in development. Infants as young as 3 weeks old have been
observed to reach out and grasp stationary and moving
objects (von Hofsten, 1982). Neonates actively control
their gaze and look at faces that engage them in a
mutual gaze (Farroni et al., 2002), and visually track
moving objects within their rst month (Bloch &
Carchon, 1992). Von Hofsten (1993) argues that behaviors that are explored in the womb (e.g., hand-tomouth behavior) may demonstrate an advantage after
birth. The evidence described in this section highlights
that infants are capable of goal-directed movements
based on visual information available in the environment (e.g., from a moving object). Although this
behavior is highly variable from trial to trial, and fragile
(it is not observed consistently), the existence of such
control provides evidence that our perceptual systems
are tuned to act on visual and haptic information from
a very early age. According to Thelen (Thelen, 1995;
Thelen & Corbetta, 1994), behavior is highly variable
when rst expressed and is gradually adapted as a result
of a dynamic process of selection of the most appropriate coordinative structures that are specic to the
contextual demands of the task.
The contextual nature of perceptual-motor behavior,
in part, is dependent on the fact that motor skills are
not simply influenced by perceptual processes but also
by biomechanical and physiologic factors. For example,
although infants are able to reach for moving targets at
the age of 3 weeks, such behavior is contingent on the
stability of their head (von Hofsten, 1982). When
the head is not stabilized, goal-directed reaching is not
observed. In a now classic example of the contextual
nature of perceptual-motor behavior, Thelen and colleagues described the case of the disappearing reflex
(Thelen, 1995; Thelen, Fisher, & Ridley-Johnson,
1984). Infants are known to demonstrate a stepping
reflex when held upright with their feet on a supporting
surface. Within a few months, this reflex pattern
of movements is not seen. The traditional explanation
for the disappearance of this reflex was that the maturing nervous system inhibited the reflex, a primitive
behavior. However, at the same time that the reflex disappears, infants also demonstrate an increase in their
body mass. When such infants were held upright partially submerged in water with their feet in contact with
a surface, the stepping reflex re-emerged, indicating
that the reflex disappeared primarily because of
increased weight and a biomechanically demanding
posture (Thelen et al., 1982; Thelen & Fisher, 1982)
M EMORY
Memory is the process by which knowledge is encoded,
stored, and retrieved (Milner, Squire, & Kandel, 1998).
The neurobiological pathways responsible for memory
are dependent on our sensory perceptual and attention
processes (discussed in the preceding sections) that
allow task-related information to be stored. Most models
of memory propose the existence of multiple systems
of memory, each devoted to a specic function
(Willingham, 1997). Memory can be classied in many
different ways: One is to classify it according to the
time scale of the operation. Thus we distinguish
between short-term (working) and long-term memory
systems.
Working memory is proposed to be a dedicated
system that holds information for short periods of time
108
Descriptions of Learning
ever, within a relatively short period of time, movements converge to a consistent topology enabling the
child to achieve the goal more consistently (Konczak et
al., 1995; von Hofsten et al., 1984).
With renement of the internal model, the abstract
representation of the movement and outcome becomes
independent of the actual environmental and biomechanical constraints. For instance, in learning the
task of writing, a child acquires an internal model of
the task. In this case the movements of the hand (and
the forces applied) that produce the form (or topology)
of a letter. Once this model is learned, the child can
perform this task not only with the dominant hand, but
with the nondominant hand as well (although not as
efciently because the nondominant hand is not as
skilled). The fact that we can produce the same action
using different effectors highlights the importance of
an internal model (abstraction) of the task that is
independent of the effectors.
Skill is rened during the later stages of learning.
Performance improves but at a much slower rate than
in the early stages of learning. In this phase improvements occur in the efciency of the movement: The
child is better able to predict the consequences of her
movement and better able to produce consistent movements from one trial to the next. According to Gentile
(1998) this phase is characterized by changes that the
performer is not aware of. The changes pertain to the
parameter specication, and include improvements in
the timing of force generation of the segments involved
in the movement and the timing and amplitude of
muscle contractions that ultimately produce the
110
EPILOGUE: RELATIONSHIP
BETWEEN COGNITIVE AND
MOTOR DEVELOPMENT
Historically, motor development and cognitive development have been studied separately and viewed as
somewhat independent of each other. It was also a
widely held belief that cognitive development occurred
over a longer period of time compared with motor
development. It is now apparent that motor skills,
particularly complex skills such as bimanual control and
some visuomotor skills, continue to develop until
adolescence. A recent development in the understanding of the relationship between cognitive and
motor development proposes that they are in fact
highly interrelated. This relationship is primarily
SUMMARY
In this chapter we have described motor skills as goal
oriented and made up of movements that are organized
to solve the spatial and temporal challenges presented
by specic tasks. In addition to the control processes
underlying motor control, we have described many
components of cognitive skills that are important for
the development and execution of motor skills. Cognitive development and motor development are closely
related and have a reciprocal relationship.
Hand function is critical in supporting cognitive
development because hand movements allow for interactions with objects that in turn support the development of knowledge about objects. Tool use with the
hands almost always requires cognitive skill to comprehend the meansend relationship of movement to
goal or outcome. In contrast with hand skills, gross
motor skills seem to require little cognitive development for their emergence.
This chapter has covered a number of topics related
to the literature on the relationship between motor
skills and cognition. The past few years have seen a
fundamental shift in the way in which we understand
the relationship of cognitive and motor skills and our
understanding of development in general. The emerging paradigm proposes that movement skills are developed not only as a function of neuromaturation, but
also through the interaction of emergent movement
and cognitive skills with the environment. This new
paradigm
emphasizes the multicausal, fluid, contextual and selforganizing nature of developmental change, the unity of
perception, action and cognition, and the role of exploration
and selection in the emergence of new behavior (Thelen, 1995).
the challenge ahead will be to develop creative therapeutic solutions that enhance skill acquisition.
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112
Chapter
CHAPTER OUTLINE
DEVELOPMENTAL THEORIES AND CONCEPTS
A Neuromaturation Model
Individual Patterns in Hand Skill Development
Hand Skills Emerge Through the Interaction of
Systems
Perception as a Primary Influence on Hand Skill
Development
Development of Hand Skills for Functional
Outcomes
CONTEXTS FOR HAND SKILL DEVELOPMENT
SYSTEMS THAT CONTRIBUTE TO THE
DEVELOPMENT OF HAND SKILLS
Posture
Sensory Systems
DEVELOPMENT OF HAND SKILLS IN THE CONTEXT
OF INFANT PLAY ACTIVITIES
A N EUROMATURATION MODEL
Early theories of motor development (Gesell, 1928;
Halverson, 1931, 1937; Shirley, 1931) emphasized the
importance of central nervous system control over
motor performance. Gesell documented an orderly
sequence of motor development, stage by stage, that
could be observed in every typically developing child.
The theory that maturation of skill and behavior resulted
from the maturation of the central nervous system
dominated understanding of motor development in the
117
118
Hand Skill Development in the Context of Infants Play: Birth to 2 Years 119
1997; Thelen et al., 1993) has explored how infants
actions and performance emerge from the interaction
of many systems, both internal and external to the
child. Factors that influence hand skills include the
infants size, growth, biomechanical attributes, neurological maturation, perceptual abilities, sensation, and
cognition (Gordon & Forssberg, 1997; Manoel &
Connolly, 1998; Thelen, 1995; Thelen, Kelso, &
Fogel, 1987). Within individual infants, these factors
vary with time, activity, and environmental conditions.
An infants actions during the performance of a task,
then, are the results of the subsystems (e.g., motor,
sensory, perceptual, skeletal, psychologic) interacting
with each other and the environment. These individual
systems are interdependent and work together, such
that strengths in one system (e.g., visual) can support
limitations in another (e.g., kinesthetic). Which systems
are recruited for the tasks varies according to the
novelty of the activity and the degree to which the task
has become automatic. For example, reaching to pick
up a cup initially is guided by the visual system, but
after it is practiced and learned, reaching is guided
primarily by the kinesthetic system, with some direction
by the visual system. In contrast, grasping appears to
initially involve primarily somatosensory input, but
later also is guided by vision. Early grasping and
manipulation patterns that are guided by visual and
somatosensory input (e.g., play with a rattle) are later
guided by cognition and memory (e.g., handwriting).
The infants sensorymotorbiomechanical systems
self organize in a coordinated way to achieve the
infants goal. For example, when an infant reaches for
the toy, grasps it, brings it to midline in hand-to-hand
play, and then to the mouth, his attention is not on
planning each of these actions. Instead, the infant is
focused on assimilating the toys actions and perceptual
features, organizing his or her movement around that
goal. Therefore developmental outcomes reflect both
an infants self organization and the opportunities in
the environment.
120
BOX 7-1
1. Exploratory activity
Learn about objects and tasks
A variety of patterns and approaches tried
Lower levels of skills used
Focus on perceptual learning about the tasks to gain
information
2. Perceptual learning and feedback acquired from
previous tasks performed
Actions initially tried and ineffective are discarded
Continue to gain perceptual knowledge about the
task
Performance is variable, demonstrating higher and
lower levels of skill
3. Discovery of the optimal solution by selecting the
action pattern that will best achieve the goal
Pattern selected is comfortable, efcient, and
indicates increased self-organization
Demonstrates flexible consistency in performance
Tends to use a stable pattern for a task (e.g., stack
blocks), but can easily adapt the pattern
according to tasks requirement (e.g., with
larger blocks, heavier blocks)
High adaptability characterizes well-learned tasks
Mature movement patterns are characterized by
adaptable stability
Synergist movements (muscles and joints working
together) are softly assembled around the goal
of the task
Specic movement patterns are observed (e.g., a
tripod grasp)
Generalizes movement patterns to other tasks when
well learned for one task
Hand Skill Development in the Context of Infants Play: Birth to 2 Years 121
use a spoon. McCarty, Clifton and Collard (1999)
noted that the transitional stage for spoon feeding is
between 14 and 19 months with an optimal solution
emerging by 19 months.
In the third phase of learning, an infant discovers the
optimal solution by selecting the action pattern that
will best achieve the goal. The pattern selected is
comfortable and efcient and indicates increased selforganization. During this last stage of learning, the
child demonstrates flexible consistency in performance.
The infant tends to use a stable pattern for a task (e.g.,
stack blocks), but can easily adapt the pattern according
to the tasks requirement (e.g., with larger blocks,
heavier blocks). High adaptability characterizes a welllearned task and mature movement patterns are characterized by adaptable stability (Gordon & Forssberg,
1997; Thelen, 1995; Thelen et al., 1987). Synergistic
movements (muscles and joints working together) are
softly assembled around the goal of the task, allowing
the infant to adapt the pattern he has learned when
task variables change. Specic movement patterns are
observed in most children, such as a tripod grasp; once
a tripod grasp is well learned, it is easily adapted to pens
and pencils of different sizes and weights. When movement patterns are well learned for one task and are
performed with flexible adaptability, the infant also
generalizes them to other tasks. McCarty and coworkers (2001) demonstrated that infants who learned
to hold a spoon with a radial grasp consistently
generalized this pattern to other tools and tasks with
self-directed goals. By 14 months, the infants consistently used a radial grasp on tools that were selfdirected (e.g., a hairbrush), recognizing it as the most
efcient grasp for using the tool.
A century of research on infant motor development
has provided a detailed description of the sequence of
hand skills development and a conceptual understanding of how infants develop hand skills. Knowledge
about the sequence allows therapists to identify infants
who may benet from intervention and to establish
goals that reflect the next skill expected to emerge. The
theories that explain how infants develop hand skills
form the basis for intervention and educational
approaches. One recurring theme in human development research, the relationship between skill development and environmental context, is discussed in the
following section.
makeup and after birth provide his learning environment. Children develop skills through participation in
their familys and communitys cultural practices.
Cultural practices are the routine activities common to
a community or people and reflect how they play,
recreate, and interact in social occasions.
The infants cultural, social, and physical contexts
expand greatly through the rst 2 years of life. The
widening context affords the infant an increasing
variety of experiences, challenges, and opportunities. In
most cultures, the rst 6 months of life are characterized by closeness to the caregiver. Often children are
held and when they are positioned for play, they are
immobile for all practical purposes. The infant is quite
dependent at this point in life, not only to have his
basic needs met, but to bring play objects within reach.
In cultures with high interdependence and strong
appreciation of extended family, the infant may be continually held by a variety of family caregivers beyond
the parents. Hand skills may be practiced on the caregivers lap by reaching for and grasping hair, jewelry, or
clothing items. First reach and grasp may be practiced
on the mothers breast.
A familys culture background influences the objects
made available to the infant. In some cultures, toys are
not valued or not available; as a result, young infants do
not experience these learning objects.
The contexts for play expand for infants after they
gain mobility (e.g., around 8 months). Because the
infant now can move to play objects, her sense of autonomy increases and she has increasing choice about
play with objects. Once the infant is mobile, she is
unlikely to spend play time on her parents lap and is
more likely to play on the floor or in a seating device
with the caregiver nearby. Being able to move to a
location or object affords the infant greater variety
of play objects, enables the infant to develop selfdeterminism, and expands the infants perception of
form, space, direction, and depth.
Cultural traditions influence how much the infant is
held, the space afforded to him or her for exploration,
and the complexity of the environment available. Infants
of families with low economic status may not have
appropriate spaces to explore and may be restricted for
safety reasons. Families of cultures that value infants
exploration and play may have more toys and activities
available. The effect of poverty on motor skills development is equivocal. Peterson and Albers (2001) found
that poverty had a small negative effect on motor
development in girls. In contrast, boys whose families
had lower income demonstrated higher motor skills
than boys from more affluent families. Using a large
sample of different ethnic and economic groups, Bradley
and co-workers (2001) found that poverty per se did
not have a negative effect on infants motor develop-
122
POSTURE
The rst stable posture of the infant is lying on his
back. Laying supine offers optimal stability; the infant
must reach against gravity, which constrains reach with
grasp. Because posture is unstable in the rst months
after birth, the 2-month-old infant primarily demonstrates asymmetric posturing, reinforced by the influence of the asymmetric tonic neck reflex (Gesell et al.,
1940). This asymmetric posture limits his or her visual
eld and reinforces visual inspection of the hands
(Bower, 1974). To reach and grasp objects, infants
must maintain stable vision of the target as they lift
their arms. Thelen and Spencer (1998) found that head
control is critical to successful reaching. In their study
reaching did not emerge in any of the infant participants until several weeks after good head control
emerged.
By 3 months, the infant has an emerging sense of
midline, and when supine brings the head to midline
and the hands toward midline. Symmetric weight
bearing in prone and increasing head control contribute to establishing a sense of midline. Neck and
shoulder stability develops as a prerequisite for control
of reach and hand movements in space.
Symmetry is the predominant characteristic of the
infants posture between 4 and 6 months. Head and
hands come to midline, enabling a hands-together
posture and visual inspection of both hands. As a result,
the infant spends much of the time in hand-to-hand
play, rst on the chest and then in space at the midline.
Head and trunk control and postural stability change
dramatically during this quartile. Thus the infant gains
important axial support for reach and use of hands in
space. Stability through the neck and shoulders helps
the infant gain control of the arms; therefore in supported positions he or she can hold her hands in space
while grasping an object. The movements of neck,
trunk, and arms appear to be coordinated early in life.
Van der Fits and Hadders-Algra (1998) found that
complex postural adjustments accompany the infants
reach by 4 months, when successful reaching emerges.
Therefore as reach and grasp emerge and later mature,
postural stability provides a base for these movements.
By 6 months, the infant demonstrates increased
postural control in the prone position, pushing onto
extended hands and shifting weight side to side. When
on elbows, the infant is able to lift one arm entirely
from the weight-bearing surface for reach to an object.
This complete lateral weight shift provides proprioceptive input through the hands across the palmar surface.
It also results in asymmetric sensory experiences. Prone
Hand Skill Development in the Context of Infants Play: Birth to 2 Years 123
Figure 7-2
Figure 7-4
Figure 7-3
124
SENSORY SYSTEMS
Figure 7-6
arms.
Hand Skill Development in the Context of Infants Play: Birth to 2 Years 125
Figure 7-7
size, and temperature. Mouthing and ngering behaviors increase signicantly from 3 to 6 months,
increasing an infants perceptual learning (Ruff, 1984)
(Figure 7-9).
Fingering behaviors are associated with visual
inspection. At 4 and 5 months of age infants
increasingly make successive oral and visual contacts
with the object, thereby integrating information from
two different sensory systems. Beginning at 5 and
6 months, infants use both hands to explore objects.
They explore textures, rotate and transfer objects, and
alternate looking with mouthing (Rochat, 1989). Ruff
and Kohler (1978) demonstrated that after 6-monthold infants tactually explore objects, they tend to
visually prefer those objects. Their results provide
evidence that an infant visually recognizes an object
that was previously held and tactually experienced but
not visualized. Sensory play at this time consists of
mouthing, hand-to-hand ngering, and intense visual
inspection.
The role of vision in guiding manipulation has an
increasingly important role after 6 months and then
throughout development (Bushnell & Boudreau,
1991). Whereas tactile input had primary influence on
grasp and manipulation, vision becomes a primary
sense for guiding the infants manipulation. McCall
(1974) reported an increase in manipulation with visual
regard at 812 months. Castner (1932) observed that
the duration of regard increased at 8 and 9 months, as
did the infants accuracy in reach and grasp of a pellet.
126
Figure 7-11
object.
Hand Skill Development in the Context of Infants Play: Birth to 2 Years 127
128
predominance of physiologic flexor tone that dominates upper- and lower-extremity movements. He or
she frequently brings the sted hand to the mouth
when prone, pulling the hands toward midline while
assuming an overall flexed position. The rst reflexive
response of the arm and hand, termed the traction
response, is demonstrated by the neonate when
proprioceptive input or traction is applied to the arm.
When the arm is pulled away from the body, synergistic
flexion of the ngers, wrist, elbow, and shoulder
results. As described by Twitchell (1970), stretch to the
flexor and adductor muscles of shoulder is a sufcient
stimulus for eliciting this response. In the rst couple of
weeks of life, the grasp reflex has not yet emerged. The
neonate may posture with sted hands, but responses
to touch on the hands result in opening or partial
opening.
It is not until the second to fourth week of life that
the infant automatically closes the ngers around an
object (or adults nger) placed in his palm. This rst
grasp reflex requires that pressure (proprioception), as
well as tactile input be applied to the palm and is
accompanied by the traction response. A grasping
reflex is not elicited in response to a visual stimulus.
By 4 weeks the grasp reflex can be elicited with a
contact stimulus to the palm or ngers. A moving
stimulus is most effective in producing this local grasp
reaction, which is immediately followed by the traction
response. By 8 weeks two distinct phases of the grasp
reflex are observed. The rst is the catching phase,
which is an immediate flexion of the ngers and thumb.
In the second or holding phase the nger flexion is
sustained. This holding is intensied if the object is
lightly pulled. The traction response declines at this
time but can be elicited when the arm is pulled from
the body (Twitchell, 1970).
By 3 to 4 months of age a true grasp reflex has
developed and the traction response no longer automatically accompanies this response, although dorsiflexion of the wrist continues to accompany the nger
flexion. When an object is placed in the hand and is
moved medially, the ngers flex in a sustaining grasp. A
palmar grasp is observed with the ngers flexing tightly
and pressing the object into the palm. Although in past
research an ulnar palmar grasp was documented to
emerge rst, more recent research shows that the index
nger is active rst and has a leading role in the rst
grasping patterns (Lantz, Melen, & Forssberg, 1996).
The grasp reflex becomes diminished at 4 to 5 months
of age and fractionation of the grasp reflex begins
(Twitchell, 1970). One or two ngers flex in isolation
from the others, given specic stimulation of their volar
surfaces. At 5 to 6 months an instinctive grasp emerges,
which combines the fractionated grasp and the
orienting response (Twitchell, 1970). At this time the
Purposeful Grasp
The transitional behaviors described previously lead to
the emergence of voluntary prehension (Gilfoyle et al.,
1990). Between 4 and 6 months the infant develops
control of grasp (Figure 7-13). Using both tactile and
visual information, she becomes skillful in adjusting
the hand to the object. The infant begins to use visual
input to prepare the hand for grasp by opening
and shaping the hand before grasp according to the
objects size and shape (Corbetta & Mounoud, 1990;
Forssberg, 1998).
These beginning abilities to grasp, orient, and adjust
the hand to objects based on tactile and visual information signify the beginning of purposeful grasp. The
infant becomes capable of using a variety of grasping
patterns that are selected based on the affordances of
Figure 7-13
Hand Skill Development in the Context of Infants Play: Birth to 2 Years 129
the objects and his or her playful intentions. Initially the
infant uses only a few grasping patterns and uses them
indiscriminately. As the infant gains experience and
matures, a variety of patterns can be observed.
At 20 weeks most infants touch, but do not grasp, a
cube placed before them. The infant who successfully
secures the cube does so by pulling it to the other hand
or the body and squeezing it against another surface.
Squeeze grasp develops by 20 to 24 weeks. The infant
presses the cube using total nger flexion against the
palm. Because his or her proprioceptive system and
motor control remain crudely developed, the cube is
squeezed tightly. Success in retaining the object is
limited by his or her ability to adjust the object within
the hand or differentiate nger movement. The thumb
does not actively participate in this grasp and tends to
lie in the palmar plane.
Finger and hand movements without object grasp
contribute to the development of grasp (Castner, 1932;
Halverson, 1931). The 4- to 5-month-old infant often
is observed scratching the supporting surface when
prone on elbows. The infant uses alternating nger
flexion and extension of the digits together. Scratching
also may occur on the caregivers clothing when
holding the infant upright against the shoulder. The
scratching motion allows the infant to practice the full
range of reciprocal nger flexion and extension.
Scratching also provides the infant with rich tactile
information about different textural surfaces.
Halverson (1931) observed rubbing of the hand on
the surface as an additional method for obtaining
tactile input in the infant at 16 to 28 weeks. As the
infant continues to use scratching, nger movements
become differentiated such that one or two ngers
move in isolation of the others. Halverson documented
pianoing or raising and lowering of each nger
alternately on the table in infants 16 to 24 weeks of
age. Pianoing appears to be an automatic movement
rather than a purposeful isolated motion of each digit.
As with other hand skills, isolated movements of the
ngers occur rst in these automatic behaviors elicited
by the sensory stimulation of the hand resting on a flat
surface.
A palmar grasp is most frequently used by the
24-week-old infant. The palmar grasp is characterized
by a pronated hand and flexion of all ngers around the
object. The thumb may slide around the object passively
rather than actively holding it (see Figure 7-13).
Halverson suggested that when thumb opposition rst
appears at 28 weeks, it is used only in association with
a palmar grasp. By 28 weeks the infant holds the object
in a radial palmar grasp (Gesell & Amatruda, 1947) or
what Halverson (1931) termed a superior palmar grasp.
The radial ngers and thumb press the cube against
the palm (Figure 7-14). Therefore when held in a
Figure 7-14
130
Figure 7-15
Automatic Release
Figure 7-16
Hand Skill Development in the Context of Infants Play: Birth to 2 Years 131
ceptual and biomechanical influences. The hand may
rst open with wrist flexion, which produces tension of
the nger extensors. The hand also may open to rub or
pat objects to perceive their sensory qualities (Bushnell
& Boudreau, 1993).
Purposeful Release
From 5 to 6 months the infant begins a transition from
reflexive to purposeful release. The infant demonstrates
release accidentally or involuntarily in association with
movements, tactile stimulation to the hand, or contact
with another surface. At 6 months release is observed
during mouthing and bimanual play. The infant brings
an object or nger food to the mouth with both hands
and may release one or both once the object is stabilized
in the mouth. When the infant holds an object with
two hands, one hand may fall from the object.
Meanwhile, the infant practices nger extension in
other activities. For example, extended ngers may be
observed in patting the bottle or toy (Figure 7-17).
Additional facilitation of nger extension in the 6- and
7-month-old child (see Figure 7-2) also occurs in the
prone-on-hands position.
At 28 weeks, the child releases an object when
transferring it from one hand to the other. Initially
object transfer is achieved by holding the object at
midline with both hands and pulling it out of one hand
into the other. Therefore the release is actually a forced
withdrawal accomplished by the opposite hand. During
this same developmental period the infant releases an
object on a table surface or another resisting (Gesell &
Amatruda, 1947) or assisting (Ammon & Etzel, 1977)
surface. Release with the assistance of another surface
enables the child to roll the object from the ngers or
remove it from the hand by inhibiting nger flexion
(i.e., without active extension).
Between 40 and 44 weeks the infant demonstrates
purposeful release in the context of play (Illingworth,
1991; Knobloch & Pasamanick, 1974). This rst active
Figure 7-17
132
Figure 7-18
Hand Skill Development in the Context of Infants Play: Birth to 2 Years 133
Figure 7-20
movements.
Figure 7-21
toys.
134
Hand Skill Development in the Context of Infants Play: Birth to 2 Years 135
Figure 7-24
136
Figure 7-27
PREHENSION: 12 TO 24 MONTHS
By 60 weeks prehension is deft and precise. The child
plans and uses grasping patterns that enable him or her
to act on the object after prehension (Gesell &
Amatruda, 1947). Fingertip grasp is used unless the
object is large and heavy or the situation is stressful for
the child (e.g., being off balance or hurried). The hand
is sufciently differentiated to hold two cubes in one
hand (Knobloch & Pasamanick, 1974). The child can
Hand Skill Development in the Context of Infants Play: Birth to 2 Years 137
now able to adapt and adjust the hand opening
according to the size, shape, and weight of the object.
Controlled release in the 2-year-old child enables him
to t puzzle pieces into their form space, place small
objects in a container, turn pages of a book, stack
blocks, and manage a cup and feeding utensils. He can
construct a six-cube tower by precisely centering each
cube and slowly releasing it, using gradual extension of
his ngers. Object release continues to develop over the
next 3 years with signicant increases in steadiness,
precision, dexterity, and speed.
SUMMARY
The childs play and the hand skills that enable that play
undergo tremendous developmental changes in the
rst 2 years of life. Exploratory play skills evolve from
generalized movements that gather comprehensive
sensory input to specic exploration of the sensory
qualities of objects. After the rst year of life, infants
exhibit functional play skills in which objects are used
as means toward a functional goal. Infants learn to use
tools as evidence of their expanding knowledge about
how objects relate and how tools can serve functional
goals. As play skills mature, the infants crude prehension patterns become precise grasping patterns that
enable skillful manipulation of objects. The child holds
objects rst in the palm, then in the ngers, and nally
in the ngertips. As she holds objects more distally,
coordination of two hands together evolves, enabling
the child to achieve greater competence and skill in play
and interaction within the environment. This chapter
described how hand skills evolve from reflexive, stereotypical patterns into precise, well-controlled prehension
and manipulation patterns.
Current research has investigated how the infant
develops hand skills. Posture, sensory functions, and
perception appear to have essential roles in hand skill
development. The activities and environments that
surround the infant afford a multitude of manipulation
opportunities. Current explanatory models explain
how hand skills develop and elucidate what variables
influence an infants developmental trajectory. These
models emphasize the influence of contextual elements
in addition to biological foundations and have application in early childhood intervention and education.
138
Table 7-1
Approximate Age
Grasp
Release
Bimanual Skill
Neonate
Traction response
1 months
Avoiding reactions
continue
2 months
3 months
4 months
Instinctive avoiding
reactions continue;
variety of hand
movements used to
avoid touch contact
5 months
Instinctive grasp;
squeeze grasp, gropes
for tactile stimulus;
adjusts hand to object
Release involuntary or
accidental
6 months
Object accidentally
released in mouthing or
bimanual play
Simultaneous, symmetric,
bilateral approach with bimanual
or unilateral prehension
7 months
Purposeful release;
transfer of object from
one hand to the other;
release against a resisting
surface
8 months
Continued
Hand Skill Development in the Context of Infants Play: Birth to 2 Years 139
Table 7-1
Contd
Approximate Age
Grasp
9 months
10 months
Release
Bimanual Skill
Object rotation by transferring it
hand to hand; plays with two
toys, one in each hand, banging
together; dissociation of
symmetric arm movement
11 months
12 months
Beginning of controlled
release; remains imprecise
Coordinated, asymmetric
movements; one hand stabilizes
and one hand manipulates
15 months
Controlled release;
increasing control when
releasing
18 months
Increasing dissociation,
strength, and perception
enable child to use tools
and manipulate objects
Controlled release,
increasing accuracy with
limited precision of
placement; tends to
extend ngers all at
one time
Asymmetric, dissociated
bimanual skills; blended stability
and mobility; alternating
sequences of two-hand
movements
Increasing competence in
two-hand tool use; increasing
complexity in movement
patterns; cooperation of
two hands
24 months
140
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Chapter
CHAPTER OUTLINE
OBJECT MANIPULATION DURING INFANCY
Movements Used in Object Exploration by Infants
Exploratory Nature of Infant Object Manipulation
Object Exploration by the Mouth and Hand
Role of Vision in Infant Object Manipulation
Handling Multiple Objects
Summary and Therapeutic Implications
OBJECT MANIPULATION DURING THE TODDLER
YEARS
Beginning of In-Hand Manipulation
Control over Object Release
Complementary Two-Hand Use
Summary and Therapeutic Implications
OBJECT MANIPULATION IN THE PRESCHOOL AND
EARLY CHILDHOOD YEARS
Studies of In-Hand Manipulation
Role of Variability in Motor Skill Development
Factors Contributing to the Improvement of In-Hand
Manipulation Skills
Summary and Therapeutic Implications
OBJECT MANIPULATION IN OLDER CHILDREN
SUMMARY
children experience success and the perception of competence. Bruner (1973) pointed out that competence
includes not only social interaction but also mastery
over objects.
The theme of this chapter is how the child gradually
gains control over the hand to manipulate objects. Infancy
appears to be a time when reach is perfected and the
basic grasp patterns are developed. At rst the infant
can manipulate objects only by grasping the object,
waving the arm, and moving the wrist because the
object is held in a power grip that xes it in the hand
(Napier, 1956). Gaining the ability to transfer an object
hand to hand greatly expands the actions the infant can
produce with the object, but it is the appearance of a
precision grip (pad of radial ngers to pad of thumb)
that marks a major change in the eventual skills of the
hand. Landsmeer (1962) indicated that the purpose of
a precision grip is to operate the object with precision
by means of the ngers. The perfection of this skill
covers a long developmental period. Voluntary release
(e.g., releasing an object in a predetermined place) also
develops in late infancy and is an important component
to skilled object interaction. Like object release, many
of the basic components for skilled hand use are seen
during infancy, but their perfection takes many years.
As an example, the child must learn to control the
release of an object so he or she can place it with skill
and accuracy. In-hand manipulation skills, or the movement of an object in the hand after grasp, are yet to be
acquired, and although the infant has the rudiments of
two-hand use, the ability to plan the movements of
both hands at the same time is not yet present.
This chapter discusses what is known about the
development of these components. There are many
gaps in our understanding of these changes and how
they might impact on the childs gradual mastery of the
143
144
OBJECT MANIPULATION
DURING INFANCY
Manipulation implies that the movement of the object
is done to achieve some purpose or goal; that is, that
the individual is consciously engaged in the activity and
directing the action. By this denition, there was a time
when researchers would not have considered studying
object manipulation in the very young infant. Neonates and young infants were considered to be primitive beings dominated by reflexes that would gradually
be integrated so the infant could engage the world.
More recent research has been guided by the belief that
infants are born curious and with a drive to explore
their universe (although admittedly within the limitations of their physical capabilities). As an example, if
properly supported and alert, neonates reach toward a
visually captured object (Bower, Broughton, & Moore,
1970; von Hofsten, 1982). Although this behavior has
been termed prereaching (Trevarthen, 1974) or prefunctional (von Hofsten, 1982), it is voluntary and has
purposefulness not seen in more reflexive behaviors.
BOX 8-1
146
148
B
Figure 8-3 Changes in an objects texture and surface
characteristics may increase higher-level manipulation
such as ngering. This gure shows two infants who are
approximately 9 months old using nger movements to
explore (A) a yarn ball, or (B) bells attached to a toy.
150
152
B
Figure 8-4 (A) Scissor cutting, and (B) bead stringing
are two of the tasks that readily demonstrate a young
childs ability to use both hands together in a task.
154
Percentage
156
100.0
90.0
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
3.0
3.6
4.0
4.6
5.0
5.6
6.0
6.6 Adult
Age
Adult
method
Internal
rotation
Surface or
other hand
OBJECT MANIPULATION IN
OLDER CHILDREN
Information about the object manipulation of older
children is limited. We do know that the speed of
movement and a decrease in variability of movement is
characteristic of older children. Finger movements get
158
SUMMARY
Efcient object manipulation depends on several
factors. There is the necessity to be able to differentiate
the movement of individual ngers and to perform this
action with speed. Manipulation skills also depend on a
grip force that is rm enough to keep the object from
dropping, but loose enough so that the object can be
moved with ease. This ability apparently is dependent
on tactile mechanisms. In addition, an object also must
be released with skill and the appropriate timing. The
ability to use the hands together is important also. Without the ability to plan and use both hands together in
a complementary fashion, the function of the hands is
severely limited. Maturation in each of these abilities
assists the childs mastery over objects and struggle
toward competence.
There is still much that is not known about the
developmental course and changes in development that
emerge as the child engages the objects in his or her
environment. We need more information on how normal
children develop manipulative skills. As an example, we
know very little about the beginning of in-hand manipulation. There are no studies on the development of
controlled release, a process that probably follows
closely on how children grasp objects. The gradation of
pressure as a child picks up, puts down, and manipulates objects deserves further study, as does the effect
of grasp force on higher-level skills, such as holding a
pen and writing. These are only a few of the areas
needing future research. Object interaction is an integral
part of human behavior, yet it is an area that has been
poorly studied. A more complete understanding of this
area of development would help both the evaluation
and treatment planning of children having difculty in
achieving competency in object interaction.
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160
Chapter
HANDEDNESS IN CHILDREN
Elke H. Kraus
CHAPTER OUTLINE
DEFINITION AND CLASSIFICATION OF
HANDEDNESS
Defining Handedness in Terms of Handedness
Dimensions
Assessment
Intervention Theory
Concluding Remarks
SUMMARY
161
162
Untrained
Trained
Hand
preference
Untrained
Hand
performance
Dimensions of
handedness
Defining HANDEDNESS
Classifications of
handedness
Consistency
Across tasks
Continuous
spectrum
Within tasks
Categories
Explicit
left
Explicit
right
Mixed
Unestablished
Variable
left
Switched
Variable
right
Pathological
Figure 9-1 Summary of aspects related to the denition of handedness. Handedness can be dened both in terms of
dimensions and classication. An important distinction is made between hand preference and hand performance as two
dimensions of handedness, each with a trained and untrained aspect. Classifying handedness can be subject to observing
the consistency of hand preference during task execution (across and within tasks), but in essence handedness is viewed
across a continuous spectrum, ranging from explicitly left handed, to various extents of handedness variability, to explicitly
right handed. However, to draw comparisons for differences and similarities between different strengths of handedness, it
is useful to divide the continuum into categories: explicit left, mixed, and explicit right. The mixed category can be divided
further into variable left and right handers, and unestablished (switched and pathological) handers.
164
Hand Preference
Several authors have dened hand preference in terms
of types or components. Bryden (1982) proposed four
types of hand preference: actions that require skill
such as using a tool, reaching actions that do not
require any skill, power actions such as carrying a
suitcase (in which one is inclined to change hands
because of fatigue), and bimanual actions in which
both hands are involved. He found that hand
preference is most signicant for tool use and bimanual
actions and least signicant for power actions and
reaching (Bryden, 1982).
Healey, Liederman, and Geschwind (1986), and
Geschwind and Galaburda (1987) suggested that one
signicant dimension of hand preference was determined by the musculature involved in task execution.
There is physiologic evidence that both the contralateral and ipsilateral hemispheres control proximal arm
muscles via multisynaptic pathways, whereas distal control of the hand and ngers is executed by the contralateral hemisphere via the corticospinal tract (Brinkman
& Kuypers, 1973; Glickstein & Buchbinder, 1998;
Haaxma & Kuypers, 1974; Peters, 1995). Support for
the distalproximal distinction was found by several
authors who observed that ne manipulations performed by distal musculature appear to be more
lateralized than gross motor tasks involving mainly
proximal musculature (Bryden, Bulman-Fleming, &
MacDonald, 1996; Peters & Pang, 1992). Other studies
only partially supported these ndings, suggesting that
the musculature used seems to be task dependent
(Case-Smith, Fisher, & Bauer, 1989; Steenhuis &
Bryden, 1989). Whether and to what extent hand preference is influenced by proximal and distal musculature
is yet to be empirically established.
Steenhuis and Bryden (1989) proposed that the
position of an object in space (i.e., ipsilateral or contralateral) influences preferred hand use, an observation
already made by Ayres (1972) years earlier. In addition,
Steenhuis and Bryden argued that hand preference
consists of two dimensions relating to skilled and
unskilled tasks. Similarly, Bishop (1990a) postulated
that when the two hands are equally skilled for a task,
either hand may be selected. As skill level differences
increase, so does the extent of preferred hand use.
Hand Performance
As with hand preference, various dimensions of hand
performance have been proposed. Some researchers
proposed that hand performance consists of two main
factors: strength, and a combination of speed and
accuracy or dexterity (Borod et al., 1984; Porac &
Untrained
Hand
preference
Functional task
performance,
including spontaneous
hand use
Trained
to developmental and environmental factors. Furthermore, it has been argued that the degree of handedness
is a more important determinant of ability than the
direction of handedness, particularly when studying
individuals who lack a distinct hand preference (Annett,
1970b, 1998; Bradshaw & Nettleton, 1983; Swanson,
Kinsbourne, & Horn, 1980).
Occupational therapists should analyze handedness
both in terms of hand preference and hand performance as two of its dimensions, because both are
subjected to different levels of training. To provide a
comprehensive context for a handedness assessment,
the genetic predisposition and environmental factors
determining and influencing the direction and degree
of handedness also should be considered (see Fig. 9-2
for an illustration of these handedness dimensions).
Handedness
Untrained
Inherent
predisposition
Hand
performance
Speed, accuracy, dexterity,
proficiency, skill
Environmental
influence
Trained
Figure 9-2 Hand preference and hand performance as two dimensions of handedness. The two dimensions of
handedness, hand preference and hand performance, are both subject to genetically based predispositions and
environmental influences. The predisposition is revealed in tasks that are not trained or practiced in any way (e.g., for
hand preference: building with blocks, opening a small box; for hand performance: tapping, hammering for speed),
although the environmental influence is manifested in trained and practiced tasks (e.g., hand preference: brushing teeth,
eating with a spoon; hand performance: drawing, cutting).
166
Handedness Classication
Annetts work has demonstrated the usefulness of using
categories of hand preference based on frequency
of use. However, in line with the present denition of
handedness consisting of both hand preference and
hand performance, handedness categories also can be
formulated in a broader sense, based on different types
or presentations. Several of these presentations have
been selected from various authors to provide a basis
for distinction (Box 9-1).
When a child presents with an unambiguous
preference for either the right or left hand, and when
this hand also demonstrates superior performance over
the other hand, he or she has established handedness
and is said to be right or left handed (Annett, 1998).
Conversely, when a child swaps hands during and
across tasks and thus presents with mixed handedness,
this is called unestablished handedness (Whittington &
BOX 9-1
Handedness Categories
Richards, 1987), because children are still in the process of developing. Adults and older children showing a
similar presentation are called mixed handers (Bishop,
1990a).
When children are inherently left handed but learn
to draw and write with the right hand, they are called
switched handers (Coren, 1992). The most obvious
difference between unestablished and switched
handedness is the clear transition from predominantly
left-handed use to right hand use because of sociocultural influences, mainly through pressure from
parents, grandparents, and teachers.
As discussed in the following, it is thought that hand
preference can be altered by neural insult, depending
on the locus and extent of lesion as well as timing
(Harris & Carlson, 1988; Liederman, 1983; Satz,
1972). If there is evidence of prenatal, perinatal, or
postnatal trauma, and one hand is signicantly weaker
and inferior compared with the other hand but still
shows some preference patterns, it is likely that this
is a pathologic handedness presentation (Soper & Satz,
1984). Because the majority of people are righthanded, pathologic left handers are far more frequent
than pathologic right handers.
Finally, ambidextrous individuals show no performance difference between the hands and can draw
or write equally well with the left and right hands
(Annett, 1998), although performing in the average or
above-average normative range. This is extremely rare,
Consistency
The left/right/mixed classication, whether categorical
or continuous, has not been the only criterion for
grouping a sample population. Consistency in hand
use is another important means of categorization.
Although several studies have investigated handedness
consistency in relation to performance domains (e.g.,
consistency and intelligence; Kee, 1991), the denition
of consistency differs among the studies. Bishop
(1990a) stressed the importance of measuring consistency within-tasks as a separate variable. She argued
that inconsistent or ambiguous hand use within a
single task (e.g., alternating right or left hand use for
throwing) might be more reflective of dysfunction than
a hand preference score. Consistency also can be
measured across tasks, whereby high consistency reflects
exclusive left or right hand performance (Peters, 1990,
1996; Peters & Servos, 1989). Thus an individual
might display inconsistency by using the left hand for
Task 1
Writing
Task 2
Pointing
Task 3
Sewing
Task 4
Throwing
1st Trial
Left
Left
Left
Left
2nd Trial
Left
Right
Left
Right
3rd Trial
Left
Right
Right
Right
4th Trial
Left
Left
Left
Right
Within-tasks consistency
(Bishop, 1990)
Always uses left hand for
this task (writing)
Across-tasks
consistency
(Peters, 1996)
Uses left hand for all tasks
Across-tasks
inconsistency
(Peters, 1996)
Uses left hand for some
and right hand for
other tasks
Within-tasks ambiguous
hand use
(Bishop, 1990)
Sometimes uses left,
sometimes right
Figure 9-3 Summary of denitions for consistency. Within-tasks consistency displays consistent hand use within a
single task (e.g., constant use of one hand when executing a task repeatedly, such as throwing a ball). If the same hand
is not used during several executions of the same task, within-tasks inconsistency is demonstrated. Across-tasks
consistency reflects the same hand use across a range of different tasks, such as writing, throwing, and cutting. Acrosstasks inconsistency is displayed by using the left hand for some tasks and the right hand for others, irrespective of withintasks consistency.
168
Switched Handedness
The concept of switched left handedness has received
attention from several theorists (Collins, 1975, 1985;
Olsson & Rett, 1989; Peters, 1990; Porac, Rees, &
Buller, 1990; Sakano, 1982; Sattler, 1998, 2001;
Steenhuis, 1996). Payne (1987) investigated older
individuals and reported the incidence of switched left
handers to be 46%, although another study found that
89% of innate left handers in the age group between
65 and 74 years had been switched, compared with
26.6% aged 35 to 44 years (Galobardes, Bernstein, &
Morabia, 1999). The authors assigned the elevated
percentage of switched handedness to increased sociocultural pressure in previous generations. However, it
has been proposed that switched handers are not easily
detected with the conventional handedness measures
(Peters & Murphy, 1992; Sakano, 1982), so the
prevalence may well be higher than 8%, as proposed by
Porac and co-workers (1986).
Individuals with an innate predisposition for left
handedness are likely to present with a notable lefthanded preference during their early childhood years
(Fischl, 1986; Olsson & Rett, 1989; Sakano, 1982;
Sattler, 1998; Stutte, Schilling, & Weber, 1977).
Parents, other family members, and teachers may exert
social pressure on children to use their right hand for
certain unimanual tasks that are culturally and socially
important. Although there has been an increased
acceptance for left handedness over the last decades,
there is still evidence of existing right-biased social
pressures in Western societies reflected in language and
social customs (Collins, 1985; Harris, 1990; Porac et
al., 1990; Sattler, 1998). Olsson and Rett (1989)
suggest that some less strongly lateralized left-handed
individuals are likely to succumb even to subtle
pressures for right hand use, eventually resulting in
switched handedness for socially important tasks (e.g.,
drawing, eating with cutlery, cutting with right-handed
scissors). Untrained tasks, on the other hand, do not
receive the same amount of attention and thus tend
to be more resistant to environmental influence (Ida,
Mandal, & Bryden, 2000; Olsson & Rett, 1989). With
repetition and practice of task execution, the right
nondominant hand can become the preferred hand
for these untrained tasks (Fischl, 1986; Harris, 1990;
Richberg, 1987; Sakano, 1982; Sattler, 1998; Stutte
et al., 1977). However, switched handers are likely to
Young & Knapp, 1966). These ndings appear to indicate that switching to the nondominant hand might
have an unfavorable effect on cortical functioning
(Sattler, 1998, 2001, 2002). Furthermore, it has been
speculated that functional specialization of the hemispheres may be altered through switching handedness,
which in turn might interfere with interhemispheric
communication processes (Olsson & Rett, 1989;
Sattler, 1998, 2001).
Initially, many children with switched handedness
compensate effectively and their problems may not arise
until their performance is challenged as school pressure
and demands increase (Fischl, 1986; Olsson & Rett,
1989; Richberg, 1987; Sattler, 1998, 2001, 2002;
Stutte et al., 1977). The nature and extent of switching
effects also seem to vary greatly among individuals,
whereby some appear to adapt more easily to right
handedness with minimal problems, compared with
others who experience great difculties (Friedmann,
1987; Harris, 1990; Sakano, 1982; Sattler, 1998, 2001,
2002). The enormous range of variation in the presenting problems (from minimal to multiple) observed in
switched handers poses a challenge in researching and
understanding the handedness behavior of these
individuals.
Today it is generally accepted that forcing or converting left handers to become right handers should
be avoided (e.g., Richberg, 1987; Sattler, 2002). Even
Coren (1996), who appeared to favor pathologic
causes as an explanation for left handedness, argued
convincingly that forcing right handedness is not the
answer:
Left-handedness is not a simple movement preference that has
developed into a habit. It probably reflects differences in the
patterns of neural circuitry in the brain (p. 261).
PREVALENCE OF HANDEDNESS
The lack of coherent denitions, standard assessments,
and universal classication procedures for handedness
(Annett, 1998; Bishop, 1990a) makes accurate estimation of the incidence of left, right, and unestablished
170
Table 9-1
ASSESSMENT OF HANDEDNESS
This section provides a brief overview of general
assessments, as found in the handedness literature, that
appear to be useful and relevant to occupational
therapists. (Specic occupational therapy assessments
related to handedness are discussed further on under
Pediatric Occupational Therapy and Handedness,
Assessment.)
Item
Pearsons r
(p < .05)
Item
Pearsons r
(p < .05)
1.
2.
3.
4.
5.
.95
.94
.90
.87
.85
6.
7.
8.
9.
10.
.84
.79
.62
.81
.69
Writing
Drawing
Throwing a ball
Using a toothbrush
Cutting with scissors
BOX 9-3
SKILL:
Tracing and dotting: Can be performed in the context
of the Motor Accuracy Test (MAc; Ayres, 1989) and
the Hand Dominance Test (HDT; Steingrber &
Lienert, 1971)
ABILITY:
Hammering (as a form of hand tapping) and tapping
(as a form of nger tapping): See Knickerbocker
(1980) for a timed hammering sample and Kraus
(2003) for a tapping adaptation.
Skill
Tracing, a prociency task subject to training,
performed with the preferred and nonpreferred hands
can demonstrate the extent to which one hand has
acquired superior control as reflected in assessment
tasks (e.g., Ayres, 1989; Steingrber & Lienert, 1971).
Similarly, several studies have employed timed dotting
as a skilled task to assess superior hand performance
(e.g., Annett, 1992a; Carlier et al., 1993; Steingruber,
1975; Tapley & Bryden, 1985). Although tracing
requires continuous motor execution, dotting involves
control of rapidly alternating stop-start movements and
placing. Even though tracing and dotting require
different types of motor prerequisites, the level of both
tracing and dotting accuracy is closely related to the
learned task of drawing and writing (Annett, 1992a;
Steingruber, 1975; Tapley & Bryden, 1985), and they
can thus be considered to be trained and skilled tasks.
Tracing and dotting are two suitable skilled hand
performance tasks, and they can be performed in the
context of the Motor Accuracy Test (MAc; Ayres,
1989) test and the Hand Dominance Test (HDT;
Steingrber & Lienert, 1971). The MAc
emphasises accuracy or steadiness of the visually directed hand
use of a pen and is specically designed for comparison between
the more- and less-accurate hands (Mandell, Nelson, &
Cermak, 1984, p. 115).
The MAc requires timed tracing of a butterflyshaped line on an A3 paper, rst with the preferred
hand and then with the nonpreferred hand. The
standardized version of the HDT for children consists
of three parts: (a) a mazelike angled path for tracing;
(b) a path of irregularly spaced circles, 0.5 cm in
diameter for dotting; and (c) rows of equally spaced
adjacent squares, also for dotting. All three tasks have
to be attempted at maximum speed and precision
for 30 seconds. The distance of the traced path is
172
Ability
Tapping as a motor performance task to assess innate
motor ability is used most frequently in research to
distinguish manual asymmetry in rapid repetitive upper
extremity movements (McManus, Kemp, & Grant,
1986) as an innate and untrained task. Numerous
studies have shown that the preferred hand taps faster
than the nonpreferred hand (Peters, 1978, 1990;
Peters & Durding, 1979; Watter & Burns, 1995).
However, stipulations for tapping differ across studies,
with some employing hand tapping controlled from the
shoulder girdle (Peters, 1990) and others using nger
tapping with stabilization of the wrist (Watter & Burns,
1995). No studies were found that investigated the
difference or similarities between these two forms of
tapping (i.e., whether and to what extent distally
controlled tapping is indeed similar to proximally
controlled tapping/hammering). For this reason, it is
useful to include both hammering (as a form of hand
tapping) and tapping (as a form of nger tapping) as
tests to assess Ability hand performance. Knickerbocker
(1980) proposed a Timed Hammering Sample to
observe the
presence or absence of established hand dominance (p. 201).
N EUROANATOMICAL AND
N EUROPHYSIOLOGICAL FOUNDATIONS
OF HANDEDNESS
Findings from scientic research link hemispheric
integration and callosal maturation to many higher
cognitive activities, such as complex problem solving,
visuomotor coordination, language skills, and social
competence, as well as handedness establishment
(Chiarello, 1980; Ettinger et al., 1972; Rourke, 1987;
Temple, Jeeves, & Vilarroya, 1990). When neuroscientists became aware of the functional asymmetry of
the brain, they regarded the two hemispheres as a leftright dichotomy of two minds, two consciousnesses
(Gazzaniga, Bogen, & Sperry, 1962). It was assumed
that the left hemisphere was dominant and superior to
the right hemisphere, particularly for speech and praxis
(Gazzaniga et al., 1962; Luria, 1973; Sperry, 1974),
whereas the right (lesser, inferior) hemisphere
provided a general context to function in nonverbal,
174
176
CONCLUDING REMARKS
In summary, hand preference can be perceived as a
multicausal behavior that is influenced by a variety of
mechanisms, including genetic and nongenetic factors.
As Provins (1997) contended:
what is genetically determined is a neural substrate that has
signicantly increased its functional plasticity in the course of
evolution. What is ne-tuned is the relative motor prociency
or skills achieved by the two sides in any given task according to
the use and the demands made on them as a result of social
pressure, other environmental influences or habit (p. 556).
Although the origin and cause of manual lateralization are still debatable, the prevalence of left and right
handedness appears to have existed fairly constantly
since prehistoric times (Bradshaw & Rogers, 1996;
Calvin, 1983; Corballis, 1983; Steele & Mays, 1995;
Toth, 1985) and across most human societies (Hardyck
& Petronovich, 1977; Harris, 1980, 1990; Peters,
1995). It could be concluded that handedness is a
unique human trait, displaying a wide variety of degrees
of presentation that are not yet well understood. In
contrast, the development of handedness has been well
documented since the 1940s, as reviewed in the
following section.
THE DEVELOPMENT OF
HANDEDNESS
Occupational therapists should have good understanding of handedness development because this forms an
important basis for the intervention phase. Dening a
developmental process of a particular behavior in the
holistic context of occupational performance most
often requires the inclusion of related behaviors. This is
also the case with the development of handedness, in
which the hands tend to be used initially in the ipsilateral hemispace before contralateral reaching with the
preferred hand is observed (Provine & Westerman,
1979; Pryde, Bryden, & Roy, 1999). Furthermore,
handedness is expressed both unimanually and bimanually (Hopkins & Rnnqvist, 1998). In particular,
Fagard (1998) argued that stabilization
of unimanual handedness might be one of the factors
influencing the emergence of the capacity to use both hands in
cooperation Bimanual complementary movements often consist of more than one step or action, in which each hand plays a
different role. The flexibility in shifting attention between hands
might therefore be one prerequisite for bimanual success
(p. 125).
In a neurodevelopmental context it seems appropriate to follow the emergence of handedness in relation to midline crossing and bimanual coordination.
The different developmental stages are discussed in the
following, rst in relation to handedness with reference
to the developmental stage of the corpus callosum, then
to midline crossing, and nally to bimanual coordination.
BIRTH
At birth, the corpus callosum is underdeveloped and
nonfunctional (Gazzaniga, 1970; Hewitt, 1962),
developing over the next 10 years at an unprecedented
rate compared with its later development. Movement
of the upper limbs has been described as uncontrolled
and reflexive, and is performed both symmetrically and
asymmetrically (Fagard, 1990, 1998), with the
presence of the asymmetrical tonic neck reflex (ATNR)
and the Moro reflex. These seemingly random movements are closely linked to the lack of postural control
at this age. For example, when the head of a neonate is
stabilized externally, reaching is possible (Amiel-Tison
& Grenier, 1980). However, adequate postural control
is necessary to enable independent reaching by the
infant, so reaching does not occur spontaneously at this
age (Shumway-Cook & Woollacott, 2001). Furthermore, the infant is unable to cross the midline, even
when the body is fully supported and one limb is
restrained (Provine & Westerman, 1979).
4 MONTHS
According to Gazzaniga (1980), each hemisphere
processes sensorimotor information independently of
the contralateral side. This activity might indicate that
the corpus callosum is starting to play a role in relaying
information from one hemisphere (e.g., visual eld) to
the other (e.g., controlling contralateral motor performance). Hand preference coincides with unilateral
swiping of either hand (Gesell & Ames, 1947) and a
decrease in the grasp reflex that is replaced with a crude
but voluntary grasp (Case-Smith, 1995). Provine and
Westerman (1979) found that this is the earliest time
that infants are able to cross the midline when one
hand is restrained (see also Murray, 1995, for a review).
Bimanual movements are symmetrical or mirrorlike
and simultaneous, resulting soon in bilateral body and
object exploration, and hand interplay in midline
(Fagard, 1990, 1998; Fagard & Pez, 1997).
178
6 MONTHS
Gazzaniga (1980) proposed that the corpus callosum
rst demonstrates increased myelination, reflected in
the emergence of unilateral reach. Alternating with the
bilateral development, a rst (transient) preference for
unilateral, usually the right hand, use becomes apparent
(Gesell & Ames, 1947). As the infants postural control
develops in sitting, weight is borne on one arm for
pivoting, and the infant reaches with the other hand to
the contralateral side using trunk rotation (Case-Smith,
1995; Gilfoyle, Grady & Moore, 1990). No active
contralateral reaching has been recorded at this stage.
There is a denite shift toward bilaterality (Gesell &
Ames, 1947) from simultaneous to successive movement (Castner, 1932). For example, the infant holds an
object in one hand and reaches with the other (White,
Castle, & Held, 1964), or movement is initiated with
one hand and completed with the other (Castner, 1932).
8 MONTHS
The emergence of a more radial palmar and then digital
grasp (Gesell & Amatruda, 1947) precedes a unilateral
phase whereby there is increased left hand use, followed
by a greater persistence of right hand use. Further
renement of postural control is now evident (CaseSmith, 1995; Gilfoyle et al., 1990), but no active
contralateral reaching has been recorded at this stage.
Infants start to hold two objects simultaneously in each
hand and combine this with a bimanual symmetric
action, such as banging (DeSchonen, 1977; Fagard,
1990, 1998; Fagard & Pez, 1997).
12 MONTHS
As the corpus callosum continues to develop, the
emerging pincer grasp coincides with another phase of
more unilateral left hand performance, followed by a
phase of using either hand (Gesell & Ames, 1947).
Having achieved good postural control in sitting, the
infant is now able to reach into either contralateral
space using trunk rotation but without employing arm
support. However, this midline crossing occurs mainly
when one hand is occupied, not yet reflecting a
preferred hand. Ipsilateral reaching is still preferred
(Carlson & Harris, 1985; Case-Smith, 1995; Knobloch
& Pasamanick, 1974), although Bruner (1969)
suggested a diminished midline barrier at this stage.
The hands begin to work together in an increasingly
complementary fashion and coordinated asymmetric
roles (Goldeld & Michel, 1986), in which one hand is
more active, the other more passive. Bimanual hand
preference emerges after 9 to 10 months of age, involv-
ing temporal and spatial coordination and complementary action. Sequential rather than simultaneous
bimanual activity is performed (Fagard, 1998; Fagard
& Pez, 1997).
18 MONTHS
Around this age, the left hemisphere develops more
rapidly than the right (Jacobson, 1978). The clear shift
toward unilateral hand use continues, alternating with
much bilateral activity, and inconsistent hand use is still
apparent (Gesell & Ames, 1947). Other researchers
have observed a clear hand preference in bimanual tasks
after 14 months (Michel, Ovrut, & Harkins, 1985;
Ramsey, Campos, & Fenson, 1979), concluding that
unimanual hand preference precedes bimanual hand
preference. More recently, Fagard and Marks (2000)
compared unimanual and bimanual tasks in relation to
hand preference in babies aged 18 to 36 months. They
found that bimanual tasks elicited a stronger role differentiation than unimanual tasks even at 18 months.
They deduced that hand preference is task related, and
that certain bimanual tasks might display greater asymmetry than unimanual tasks in infancy. At this stage, the
rst active contralateral reaching across the body is
observed (White et al., 1964), without one hand being
occupied or used for support. Children are now able
to combine stabilizing the object with one hand and
manipulating it with the other in an alternating manner
(Gilfoyle et al., 1990), which leads to more mature
bimanual coordination (Corbetta & Thelen, 1996;
White et al., 1964).
24 MONTHS
The corpus callosum appears to be functioning at a
basic level and inhibitory function is emerging (Farber
& Knyazeva, 1991). There appears to be a preference
for bimanual activity in which the preferred hand is
more active and the nonpreferred hand has a stabilizing
and assistive role (Fagard & Marks, 2000). At this stage,
most young children show a more denite preference
for the right hand (Gesell & Ames, 1947) because the
ngers and arms are increasingly dissociated for a large
variety of functional skills (Case-Smith, 1995). Stilwell
(1987) found that 2-year-old children actively cross the
midline, more so with their preferred hand. The hands
can now be used in all planes with good control
(Gilfoyle et al., 1990). Two-year-old children can also
perform a sequence of bimanual movements whereby
the arm and hand stabilization and movement are
controlled simultaneously (Knobloch & Pasamanick,
1974), such as holding a crayon and drawing, or
threading beads.
2 TO 6 YEARS
MRI studies have supported age-related increases in
cerebral white matter and myelination of the corpus
callosum in children and adolescents (DeBellis et al.,
2001; Giedd et al., 1999; Thompson et al., 2000).
There is evidence that callosal transfer is not optimal
until approximately 10 to 12 years (Yakovlev &
Lecours, 1967), and that subsequent sensorimotor and
cognitive development further increase the callosal
interconnections between the hemispheres up to
adulthood (Pujol et al., 1993).
By the third and fourth year, the direction of hand
preference is evident (McManus et al., 1988) and there
is a tendency toward unilateral activity (Gesell & Ames,
1947). This stage appears to be followed by another
period of well-differentiated bilaterality between 5 and
7 years of age. Hand preference becomes fully established between 6 and 9 years of age (Gesell & Ames,
1947; Tan, 1985). At the age of 6 years children use
the preferred hand consistently to cross the body midline (Stilwell, 1987). However, more complex tactile
tasks requiring crossed localization conditions demand
a higher level of interhemispheric transfer via the
corpus callosum (Fabbro, Libera, & Tavano, 2002).
Children aged 5 to 6 years make signicantly more
errors than 10-year-olds (Quinn & Geffen, 1986).
Children are increasingly able to execute complex
activities requiring differentiated hand performance, in
which the asymmetrical and functional role differentiation becomes more rened throughout childhood
(Fagard, 1990, 1998). Symmetrical in-phase coordination between the hands is evident at 5 years (Fagard,
1987), but inconsistent coordination patterns are still
observed in children between the ages of 6 and 10 years
(Haken, Kelso, & Bunz, 1985).
Unimanual action such as grasping might strengthen
the contralateral unilateral control system during
infancy (Fagard, 1998). This allows one hand to take
responsibility and lead, which in turn influences hand
preference and the dissociation between the hands.
Bimanual action, on the other hand, allows infants to
use both hands in succession until they are able to
coordinate their hands in an asymmetrical and simultaneous manner (Fagard, 1998). With maturation,
reaching and grasp extend to midline and then to the
contralateral space, possibly indicating a shift in
interhemispheric communication from extracallosal to
callosal control (Liederman, 1983). This contralateral
reaching or midline crossing has been dened as
hand movements that approach and/or cross the centre
longitudinal axis of the body (the body midline) (Stilwell,
1994).
PEDIATRIC OCCUPATIONAL
THERAPY AND HANDEDNESS
ASSESSMENT
Tests Used in Occupational Therapy
There is a lack of specic test procedures in occupational therapy to assess handedness. The Mesker test
was designed specically to assess writing handedness
for children at school entry (Mesker, 1972). This test
was used by occupational therapists in the United
Kingdom and involves simultaneous drawing with both
hands. However, ndings from an evaluative study
indicate that hand preference could not be conrmed
denitely using the Mesker test (Warren & McKinlay,
1993).
Two assessments that include aspects of handedness
in children are frequently used in occupational therapy;
the Southern California Sensory Integration Tests
(SCSIT) (Ayres, 1980) and the Sensory Integration
and Praxis Tests (SIPT) battery (Ayres, 1989). Because
there is some evidence that
limitations in development of unilateral hand preference may
be associated with poor functional integration of the two sides of
the body [and] with diminished preferred-hand visuo-motor
coordination (Ayres & Marr, 1991, p. 233),
180
I NTERVENTION THEORY
Unestablished Handedness
Occupational therapy intervention for unestablished
handedness has its roots in perceptual motor theory
(Keogh & Sugden, 1985; Kephart, 1971; Lerch,
Becker, & Nelson, 1974), sensorimotor principles
(Knickerbocker, 1980), and sensory integration (Ayres,
1972, 1989). Laterality has been dened by early
perceptual motor theorists as
the internal awareness of the two sides of the body and their
difference (Kephart, 1971, p. 88).
Performance Level
Below
Border
Average
Inter-Hand Difference
Handedness Aspect
Untrained FHP
Trained FHP
Skill
Ability
Midline Crossing
Bimanual Coordination
Figure 9-4 Example of a handedness prole chart combining performance levels and interhand differences.
Note: FHP = Functional Hand Preference, L+ = explicit left handedness, L = moderate left handedness, V = variable
handedness, R = moderate right handedness, R+ explicit right handedness. This handedness profile is based on an
8-year-old boy with PDD who had left-handed tendencies but was encouraged at home and in therapy to use his right
hand. (Kraus, 2004)
182
handedness seems appropriate, because an overall development of laterality may well assist in establishing
handedness. However, older children presenting with
unestablished handedness pose the greatest challenge,
particularly so if a decision on handedness is eminent
because of school entry. Based on the current handedness knowledge discussed so far, assessment results
should be analyzed carefully before embarking on
clinical decision making. How do we know if a child is
inherently left or right handed? Are there other factors
to consider before making a nal decision? What is the
most benecial treatment for that child? In her doctoral
thesis, Kraus (2003) methodically evaluated existing
handedness measures, proposed several different
reasons why children could present with unestablished
handedness (or types of variable handedness), devised a
novel assessment battery and suggest treatment guidelines in the context of her Handedness Prole. This
process could be one way to deal with these questions,
but it extends beyond the scope of this chapter. In the
absence of evidence-based practice to substantiate
certain treatment approaches, differential handedness
assessment methods are crucial.
Switched Handedness
When addressing switched handedness flag a note of
caution. Although many of a childs presenting
problems might be related to, or caused by, switched
handedness (Fischl, 1986; Friedman, 1987; Harris,
1990; Olsson & Rett, 1989; Richberg, 1987; Sattler,
1998; Stutte et al., 1977), unswitching might not be
favorable in every case because there appear to be certain preconditions for successful handedness retraining.
According to Sattler (1998), these preconditions
include the following: (a) full support for the retraining
process of parents and teachers; (b) a relatively stressfree situation with flexible time constraints on writing,
and limited writing volume; (c) sufcient motivation of
the child; and (d) a skilled therapist experienced with
handedness issues. In addition, based on my own clinical
experience as an occupational therapist, average or
above-average motor performance level of the left
hand, regular occupational therapy sessions, monitoring of progress, and regular follow-up (including close
contact with parents and teachers), also are necessary
for a successful handedness retraining outcome. Age
does not appear to be a major factor for successful
retraining because numerous case studies exist of adult
switched handers who have successfully retrained their
original or dominant handedness (Sattler, 1998). A
case study, based on the Handedness Prole (Kraus,
2003), illustrates the clinical decision making process
for a child with switched handedness (Box 9-4).
However, a note of caution: Until therapists are
more familiar with the dynamics and associated
Left Handedness
In most aspects, there are no differences between
treating left and right handed children in therapy,
because motor problems are common in both groups
and should be treated according to the same principles.
However, two intervention areas require specic attention for left handers: writing and those ADL activities
that involve utensils designed for right handers.
Writing
The act of writing from the left to the right is conducive to right handers, who engage in a pulling
motion across the page whereby the written work is
clearly visible. Left handers have to adhere to the same
left-to-right direction in writing and thus should apply
a pushing motion that is more difcult to control.
Furthermore, if left handers employ the mirror image
hand position of right handers during writing, the left
hand obscures the written work, and if a fountain pen
is used, smudges it. The pushing action and visual
limitations seem to be the main reasons why many left
handers develop compensatory positions that often
result in an unfavorable, cramped writing grasp with
wrist flexion. Although the pushing action may be
more laborious when learning to write, this is no reason
to switch a left-handed child to right-handed writing,
because there is evidence that left handers are able to
develop the same writing speed as right handers
(Sattler, 2001). However, if a child learns to use a
hooked or clawed writing position through compensation, this is more likely to impede on the speed,
legibility, and ergonomics of writing.
In therapy it is thus crucial to establish the correct
writing pattern for left handers. The basic principles are
the same as in right handers:
90-90-90 position at hips, knees, and feet, with
table height two ngers above the adducted elbow;
good upright posture
The upper arm only abducts slightly when the forearm moves outward to the side, and the elbow does
not protrude sideways
Lateral support of the ulnar side of the hand and
wrist extension
Rened and relaxed tripod grip enabling intrinsic
nger movement
The following principles are specic to left-handed
writing:
Paper or exercise book placed slightly toward the left
of the body midline with the left top corner slanted
between 20 and 40 up to the left
BACKGROUND INFORMATION
Tim (6 years and 6 months old) presents with righthanded writing. A history of early left hand use is
reported, and both father and sister are self-reported
switched left handers. There are indications of sociocultural pressure for right hand use, with Tims father
openly advocating the need to switch left handedness to
right handedness. There is a history of birth-related stress
and general mild developmental delay.
HANDEDNESS PROFILE
Untrained hand preference tasks: More left than right
responses, below average performance, inconsistent
within and across tasks
Trained hand preference tasks: Slightly more right than
left responses, below-average performance, inconsistent
across tasks mainly
Hand performance ability: Signicantly more right than
left responses, average performance
Hand performance skill: Signicantly more right than
left responses, below average performance
Midline crossing: Crosses more frequently with the left
but overall avoids contralateral reaching
Simple bimanual coordination (bimanual circle drawing): Leads more with the left, average performance
Overall classication: Variable left hander
DISCUSSION AND INTERPRETATION OF RESULTS
The handedness prole indicates both within-task and
across-task inconsistency, in which the left hand is used
more for untrained tasks (mild left) and the right slightly
more for trained tasks (variable right). There was no
184
CONCLUDING REMARKS
Considering the complexity of handedness, it seems
unlikely that there is one standard treatment approach
that could effectively enhance the establishment of
handedness, or that a certain combination of approaches is effective in all cases. Although the appropriateness and effectiveness of these treatment
approaches in addressing unestablished handedness has
still to be determined, it is proposed that the therapist
should be familiar with different types of intervention,
applying one or more approaches as deemed most
benecial to each individual child. Furthermore, the
development of handedness, in relation to the development of midline crossing and bimanual coordination,
provides valuable guidelines for therapy.
SUMMARY
This chapter has demonstrated that handedness is a
variable, complex, interactive, and multidimensional
phenomenon subject to hereditary, environmental, and
social influences. To understand and assess handedness
not only in this context but also in terms of function
within occupational performance, those behaviors
closely linked to handedness, function, and environment
(i.e., bimanual coordination and midline crossing)
should be assessed. The development, publication, and
standardization of a comprehensive handedness assessment tool that satises these criteria is still pending, as
is the analysis of the results for clinical decision making.
A comprehensive assessment procedure is a crucial
research tool for investigating the nature of unestablished, left and right handedness as well as the effectiveness of different treatment approaches. It can be
concluded that handedness is a pediatric specialist area
in occupational therapy that is in need of much
empirical evidence and support.
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Amazeen EL, Amazeen PG, Treffner PJ, Turvey MT
(1997). Attention and handedness in bimanual
coordination dynamics. Journal of Experimental
Psychology: Human Perception and Performance,
23(5):15521560.
Amiel-Tison C, Grenier A (1980). Evaluation neurologique
du nouveau et du nourrisson. Paris, Masson.
Amunts K, Jncke L, Mihlberg H, Steinmetz H, Zilles K
(2000). Interhemispheric asymmetry of the human motor
cortex related to handedness and gender.
Neuropsychologia, 38:304312.
Annett M (1970a). The growth of manual preference and
speed. British Journal of Psychology, 61(4):545558.
Annett M (1970b). A classication of hand preference by
association analysis. British Journal of Psychology,
61(3):303321.
Annett M (1972). The distribution of manual asymmetry.
British Journal of Psychology, 63:343358.
Annett M (1976). A co-ordination of hand preference and
skill replicated. British Journal of Psychology,
67(4):587592.
Annett M (1978). Genetic and non-genetic influences on
handedness. Behavioural Genetics, 8:227249.
Annett M (1985). Left, right, hand and brain: The right
shift theory. Hillsdale, NJ, LEA.
Annett M (1992). Five tests of hand skill. Cortex, 28:583593.
Annett M (1994). Handedness as a continuous variable with
dextral shift: Sex, generation, and family handedness in
subgroups of left- and right-handers. Behavioural
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Annett M (1995). The right shift theory of a genetic
balanced polymorphism for cerebral dominance and
cognitive processing. Cahiers de Psychologie, 14:427480.
Annett M (1998). The stability of handedness. In KJ
Connolly, editor: The psychobiology of the hand,
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Ardila A, Ardila O, Bryden MP, Ostrosky F, Rosselli M,
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abilities in forced left-handers. Developmental
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Ayres AJ (1972). Sensory integration and learning disorders.
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Sensory Integration Tests. Los Angeles, Western
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Ayres AJ (1980). Southern California Sensory Integration
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Ayres AJ (1989). Sensory Integration and Praxis Test. Los
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Ayres AJ, Marr DB (1991). Sensory Integration and Praxis
Tests. In AG Fisher, EA Murray, AC Bundy, editors:
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186
188
190
Chapter
10
CHAPTER OUTLINE
IMPORTANCE OF INDEPENDENCE IN SELF-CARE
Importance to the Child
Self-Care in Disability
MEASUREMENT
Nonstandardized Measures
Standardized Instruments
FACTORS IN THE ACQUISITION OF SELF-CARE
Social and Cultural Influences
Sex Differences
Maturation
Mastery Motivation
Motor Factors
CHRONOLOGY OF SELF-CARE ACQUISITION
Eating
Dressing
Hygiene and Grooming
DISCUSSION
Hand Skills in Self-Care
Perceptual Factors in Self-Care
Cognitive and Personality Factors in Self-Care
SUMMARY
193
194
IMPORTANCE OF INDEPENDENCE
IN SELF-CARE
SELF-CARE IN DISABILITY
MEASUREMENT
NONSTANDARDIZED M EASURES
Since the early years of the profession, therapists have
been concerned with the assessment and treatment of
dysfunctional self-care performance. One of the rst
known checklists of self-care performance was published
in 1935 (Wolf, 1969); since that time assessment of
function has been traditional in both occupational and
physical therapy. Assessment forms were published
from time to time in the early years, but more often
treatment settings designed forms to meet the needs of
their particular caseloads and treatment settings.
Developmentally oriented functional assessments
that incorporated information on child growth and
development came into use in the 1940s, and developmental scales that included basic self-care were
published a few years later. For example, an upperextremity motor development test that included agekeyed items on feeding, dressing, and grooming, as
well as hand use, was developed at the New York State
Rehabilitation Hospital (Miller et al., 1955). Such
instruments used information on ages at which children
typically master skills, and grouped the skills by the age
at which achievement might be expected.
One of the reasons therapists have continued to construct their own instruments is because of the need for
greater detail in planning treatment programs for different disabilities. Breakdown of self-care activities is
different for a child with a congenital amputation,
cerebral palsy, spina bida, or mental retardation. Both
center-made and published scales are designed for dayby-day guidance of intervention and are as detailed
as available knowledge allows. Some published nonstandardized instruments have been designed for
specic disability areas. For example, a comprehensive
tool for evaluating childrens self-sufciency in self-care
activities was developed by the Occupational Therapy
Department at Childrens Hospital at Stanford,
STANDARDIZED I NSTRUMENTS
Derived normative age information for developmental
scales is at best only fairly accurate, and the information
on individual children is descriptive only. Meaningful
overall scores are not obtainable because there is no
way of weighing individual items. Therefore they are
not appropriate for use in research or the documentation of overall progress.
Two pediatric assessments designed for the functional evaluation of children with disabilities and the
reliable documentation of change were developed and
standardized in the 1990s and are now in wide use in the
United States, as well as in other countries. They are
the Wee Functional Independence Measure (WeeFim)
(State University of New York at Buffalo, 1994) and
the Pediatric Evaluation of Disability Inventory (PEDI)
(Haley et al., 1992). Both include sections on basic
self-care and have been demonstrated to be valid and
reliable (Ottenbacher et al., 2000). The two instruments are highly correlated (Ziviani et al., 2001): Each
has its advantages. The PEDI gives more depth of
information but the WeeFim is easier and faster to
administer.
196
SEX DIFFERENCES
Early literature reported several differences between
girls and boys in the age at which self-care skills are
acquired. Gesell and Ilg (1943) wrote that boys
demand independence in dressing at a younger age
than girls. Key and co-workers (1936) reported
tentative sex differences in dressing ability between 212
years and 412. Girls were more skillful than boys and
tended to dress faster, and the ability of boys generally
was more variable than that of girls. Sources of the
differences in the ages at which dressing skills are
achieved have been proposed. It has been thought that
girls dress themselves earlier than boys because their
wrists are more flexible, they are better coordinated,
and they wear simpler clothing (Coley, 1978; Gesell et
al., 1940; Key et al., 1936). A difference also has been
reported in the use of eating utensils in self-feeding
(Gesell & Ilg, 1943). Girls shifted to an adult grasp
earlier than boys, some as early as 3 years. Some boys,
on the other hand, continued to use a pronated grasp
at 8 years of age. Boys also were reported to sometimes
demand to feed themselves before they were competent
to do so.
One recent study has also shown a difference between
the sexes. In China, younger girls were reported to score
higher than boys on the self-care subscores of the
WeeFim (Wong et al., 2002). However, no sex differences in overall functional ability were found in research
in the United States on the PEDI (Haley et al., 1992).
MATURATION
Although culture and family expectations play a role, it
seems clear that the greatest factor in the achievement
of self-care skill in childhood is maturation. Certainly
Gesell and his associates thought so, and self-care items
are prominent in his developmental diagnosis (Gesell &
Amatruda, 1965). This supposition was borne out by
the research of Key and her associates (1936), who
found the correlation between dressing ability and
chronological age to be considerably higher than that
for mental age or any other factor. Furthermore, the
composite score of self-care, mobility, and social
functions of the PEDI showed high and signicant
correlation with age but not with demographic
variables.
MASTERY MOTIVATION
The concept of mastery motivation has its roots in the
writings of Robert White (1959), who proposed that
the development of competence in young children
grew out of a pleasurable sense of efcacy when they
successfully manipulated objects. The toddler and
198
MOTOR FACTORS
Coley (1978) identied sequences of gross and ne
motor development leading to independence in selfcare tasks. Examples of necessary gross motor abilities
needed for dressing are reaching above the head or
behind the back while maintaining trunk stability. Selffeeding requires head and mouth control, as well as
trunk stability. Coley identied steps in the motor
control leading to many individual self-care skills, and
they are discussed within each self-care domain. They
include bilateral skills, nger manipulation, and tool
skills. Children learn one-handed skills before bilateral
skills, and some skills are achieved later because of
the need for the two hands to work together. An early
example is holding a bowl with one hand while
scooping with the other. Children become functional
in the performance of skills during their preschool
years, but complete independence and adult levels of
CHRONOLOGY OF SELF-CARE
ACQUISITION
The following pages present developmental patterns
and the ranges of ages in which typical children learn
to care for their own daily needs. This information is
presented as a summary of what is currently known
about the chronology of the acquisition of skill in selfcare as a source for the understanding of the process by
which skills are acquired. The immediate purpose is to
allow a preliminary analysis of the relationship of the
acquisition of self-care skills to the development of
hand skills. The information that follows has been compiled from different sources to provide as much detailed
information as possible. The childs attempts at performance are included because they show an understanding of the task, and the practicing of subskills
reflects motor abilities. The developmental information
in the following discussion is organized into the domains of eating, drinking, dressing, personal hygiene,
grooming, and simple household tasks. The items listed
in the charts are steps in the learning of self-care that
various authors have observed and reported. We have
no denitive information as to the universal consistency
of the sequences presented: They are based on reports
of ages at which children are usually self-sufcient in
discrete skills.
The area of research that has provided the most
information on the acquisition of specic self-care skills
EATING
The progress of a childs self-feeding behavior requires
both the acquisition of skill in the use of eating utensils
Finger Feeding
Self-feeding with the ngers begins in the second half
of the rst year. Table 10-1 shows the development of
the skill, which parallels the infants acquisition of hand
skills. Initial feeding is of crackers held in the hand and
sometimes plastered against the mouth with the palm
and with the forearm supinated. As nger skill
develops, bite-size pieces of food are picked up and put
into the mouth with a pincer grasp. Even when spoon
use has become skillful, children prefer to use ngers
for discrete pieces of food such as peas or meat (Gesell
& Ilg, 1943).
200
Table 10-1
Skill
Age
Source
6 mo1 yr
67 mo
Coley (1978)
9 mo
10 mo
Coley (1978)
1 yr
1 yr
Coley (1978)
Table 10-2
Skill
Age
Source
6 mol yr
10 mo
1122 yr
1 yr
1 yr 3 mo
1 yr 3 mo
1122 yr
112 yr
Coley (1978)
1 yr 9 mo
Coley (1978)
Holds cup or glass with one hand, free hand poised to help
2 yr
3312 yr
3 yr
Use of Utensils
Table 10-3 shows the chronology of the development
of the use of spoons, forks, and knives. The many years
necessary for learning to use utensils reflects the
complexity of their use, particularly the knife and fork
in cutting. The infant begins eating with a spoon held
in a sted grasp, with the arm pronated and shoulder
abducted. The adult nger grip, with forearm supination and rotation as needed, requires more ne motor
control and dexterity (Haley et al., 1992) but does not
develop until approximately 3 years in girls (Gesell et
al., 1940); some boys continue to use a pronated
pattern at 8 years (Gesell & Ilg, 1946). The sted grasp
appears again in the use of forks and knives in cutting.
It appears that the force needed for holding and cutting
requires the power of the whole hand and the necessary
power combined with the nger dexterity for cutting is
not developed until a child is about 10 years old.
Studies of Spoon Use
The spoon is the rst tool used by most infants
(Connolly & Dalgleish, 1989). Several studies of spoon
use have been reported, two involving infants and one
preschool children. The earliest study was of nursery
school childrens eating behavior (Bott et al., 1928).
The eating behaviors included in the study were (a) the
proper use of utensils, (b) putting the proper portion of
food on a utensil, and (c) coordination, as indicated by
minimal spilling. They found improvement with age in
all these behaviors, but the behaviors differed as to
when they improved. The use and lling of the utensils
improved primarily between 2 and 3 years of age, but
spilling decreased more between 3 and 4 years.
A cinemagraphic study of infant eating behavior
conducted by Gesell and Ilg (1937) described both
prespoon activity and early spoon use. Preparation for
using the spoon began when a child was being fed.
Between 3 and 6 months of age the child watched the
spoon, and soon mouth opening began in anticipation
of the spoon reaching the mouth. Later, head movements began with movement of the head toward the
spoon and then away as food was removed. Whereas
initially food was put in the mouth by the adults
manipulation of the spoon, the child later removed
food by lip compression. These movements of the head
and lips were considered to make later spoon manipulation more effective.
Gesell and Ilg noted that even as simple a tool as a
spoon requires a sequence of perceptual and motor
acts. One act is the discriminative grasp of the spoon
handle. Infants rst grasped the lower third of the
handle, later the middle to upper third, and nally the
end. Grasp was at rst palmar, with the thumb wrapped
around the spoon, but later the thumb was placed
along the handle. The adult grasp usually was not seen
until 3 years of age. A second perceptual and motor act
is the lling of the spoon. At rst the bowl of the spoon
is merely dipped in the dish, often with the spoon
handle perpendicular. Filling began with a rotary movement toward the body, and it was not until 16 months
that children began lling the spoon by inserting its
point into the food. Lifting the spoon was at rst
accomplished with the arm pronated, and often with
the bowl of the spoon tipping. By the end of the
second year children were lifting their elbows and
flexing their wrists. The insertion of the spoon into the
mouth also changed from the side into the mouth to
the point into the mouth.
The third study reported by Connolly and Dalgleish
(1989) conrmed many of the ndings of Gesell and
Ilg. They conducted a comprehensive videotape study
on the longitudinal development of spoon use. The
research procedure was more formal, and the study
can serve as a model for the investigation of the learning of complex motor skills. The authors rst presented
an analysis of spoon use that included both intentional
and operational aspects. The task was described as
entailing:
(a) an intention to eat, which involves the childs motivation; (b) some knowledge about the properties of the spoon as an
implement with which to effect the transfer of food from dish to
mouth; (c) the ability to grasp and hold the spoon in a stable conguration; (d) the loading of food onto the spoon; (e) carrying the
loaded spoon from dish to mouth; (f) controlling the orientation
of the spoon during this transfer to avoid spillage; and (g) emptying the spoon and extracting it (p. 897).
202
Table 10-3
Skill
Age
Source
1011 mo
1 yr 3 mo
1 yr 3 mo
Coley (1978)
1122 yr
112 yr
Coley (1978)
112 yr
112 yr
2212 yr
2 yr
2 yr
2 yr
3 yr
3 yr
4 yr
Coley (1978)
46 yr
Coley (1978)
2212 yr
412 yr
Co1ey (1978)
5512 yr
67 yr
Coley (1978)
5512 yr
78 yr
Coley (1978)
8 yr
SPOON
FORK
KNIFE
DRESSING
The development of self-care in dressing, undressing,
and managing fasteners also parallels and depends on
the development of hand skills. A sted grasp is sufcient for the tasks of removing hat and socks. Pulling
up pants requires more strength and bilateral coordination than pushing them down and kicking them off.
204
Table 10-4
Skill
Age
Source
Unwraps food
1122 yr
Vulpe (1979)
Opens jars
2 yr
45 yr
Vulpe (1979)
Serves self
45 yr
Vulpe (1979)
Makes sandwich
7 yr
Brigance (1978)
8 yr
2212 yr
Vulpe (1979)
3312 yr
4412 yr
6 yr
Brigance (1978)
Uses napkin
4 yr
Brigance (1978)
2123 yr
Vulpe (1979)
Wipes up spills
3 yr
45 yr
Vulpe (1979)
PREPARES FOOD
PREPARES DRINKS
OTHER SKILLS
Table 10-5
Skill
Age
Source
Up to 3 mo
Vulpe (1979)
6 mo
Vulpe (1979)
69 mo
910 mo
Vulpe (1979)
36 mo
Vulpe (1979)
9 mo
Coley (1978)
1122 yr
1418 mo
Vulpe (1979)
2212 yr
2 yr
Coley (1978)
Interested in lacing
2123 yr
Vulpe (1979)
Reaches to toes
1 yr 4 mo
Coley (1978)
25 yr
Coley (1978)
36 yr
Coley (1978)
46 yr
Coley (1978)
COOPERATION
Attempts skill
TRUNK STABILITY
206
Table 10-6
Skill
Age
Source
112 yr
Removes mittens
1214 mo
Coley (1978)
1122 yr
1122 yr
23 yr
Coley (1978)
1 yr
2124 mo
2212 yr
1 yr
Brigance (1978)
1 yr
Brigance (1978)
2123 yr
Assistance needed
3 yr
Coley (1978)
4 yr
Coley (1978)
Table 10-7
Skill
Age
Source
2 yr
3 yr
Coley (1978)
3312 yr
4 yr
112 yr
3312 yr
2 yr
212 yr
Vulpe (1979)
4125 yr
34 yr
Vulpe (1979)
4125 yr
2 yr
Coley (1978
2 yr 9 mo
Coley (1978)
3124 yr
3 yr
2 yr
3312 yr
312 yr
3 yr
4 yr
Coley (1978)
2 yr
2212 yr
3312 yr
4 yr
Coley (1978)
4 yr
Coley (1978)
HAT
Puts on, may be backward
SOCKS
SHOES
208
BOX 10-2
Table 10-8
Skill
Age
Source
112 yr
Brigance (1978)
2123 yr
Vulpe (1979)
3 yr
Coley (1978)
Laces shoes
45 yr
Coley (1978)
5 yr 3 mo
Coley (1978)
66 2 yr
5 yr
Coley (1978)
6 yr
Coley (1978)
8 yr
Coley (1978)
Ties necktie
10 yr
Coley (1978)
3 yr 9 mo
Coley (1978)
4 yr
Coley (1978)
412 yr
Coley (1978)
4125 yr
1 yr
Brigance (1978)
3 yr
Brigance (1978)
BUCKLES
VELCRO FASTENERS
Manages shoes with Velcro
SNAPS
3 24 yr
6 yr
Coley (1978)
2212 yr
312 yr
Coley (1978)
412 yr
Coley (1978)
4 yr 9 mo
Coley (1978)
512 yr
Coley (1978)
5126 yr
212 yr
Coley (1978)
3 yr
Coley (1978)
312 yr
Coley (1978)
4412 yr
6 yr 3 mo
Coley (1978)
ZIPPERS
BUTTONS
210
Table 10-9
Hygiene
Skill
Age
Source
1122 yr
1 2 yr
Coley (1978)
1122 yr
2123 yr
Coley (1978)
3 24 yr
3 2 yr
3 24 yr
3 yr 9 mo
Coley (1978)
4 yr
Coley (1978)
6 yr
Coley (1978)
5126 yr
Without supervision
4 yr 9 mo
Washes ears
89 yr
1122 yr
3 yr
Coley (1978)
WASHING FACE
BATHING BODY
4 2 yr
Coley (1978)
12 yr
1122 yr
2212 yr
3 24 yr
TEETH BRUSHING
4 25 yr
4 25 yr
7 yr
Coley (1978)
1122 yr
22 2 yr
33 2 yr
1122 yr
6612 yr
2212 yr
33 2 yr
33 2 yr
5 26 yr
5 yr
Coley (1978)
NOSE CARE
Allows wiping of nose
Wipes on request
TOILETING
Assists with clothing management
Manages clothes before and after toileting
Tries to wipe self after toileting
Manages toilet seat, toilet paper, flushes
33 2 yr
1
212
Table 10-10
Grooming
Skill
Age
Source
1112 yr
1112 yr
2123 yr
7 yr
7 yr
Coley (1978)
12 yr
Coley (1978)
Shines shoes
7 yr
Brigance (1978)
12 yr
Coley (1978)
512 yr
Coley (1978)
8 yr
Coley (1978)
HAIR
DISCUSSION
Independence in the performance of the daily activities
of basic self-care requires the mastery of complex hand
skills that children learn over many years. The skills
have varying degrees of manipulative, perceptual, and
cognitive components and the action sequences are
learned through extensive practice until they become
automatic and efcient. We have some knowledge of
the usual ages at which the skills are mastered, but very
little knowledge of what Connolly and Dalgleish
(1989) called the general patterns of behavioral
change, which occur as children acquire specic selfcare skills.
Most of the studies of the development of self-care
skills cited in this chapter were conducted before 1940.
There are not many, and recent studies are even scarcer.
As noted by Amato and Ochiltree (1986), despite an
increasing interest in the development of competence
in childhood during the last decade, practical life skills
have been virtually ignored. Interest in the study of
childrens self-care skills over the years has been largely
limited to their use in identifying developmental milestones, and most of our knowledge is of that kind. The
information in this chapter is a summary of what is
currently known about the chronology of skill acquisition and is presented as a possible source for nding
clues to the understanding of the process by which
skills are acquired.
Although the ages identied are approximate and
represent an unspecied average behavior, they provide
a tentative chronological order in which skills and
subskills develop. However, it must be remembered the
sequences of skill development that are suggested by
the information in the tables may be an artifact of the
use of group data. Of course, some of the steps in
learning are clearly acceptable; that is, a partial skill
precedes a complete skill and many of the sequences
have been repeatedly observed and veried by teachers,
parents, and therapists. However, individual differences
among children could result in different routes to
competence in an overall skill. Nevertheless, these overall sequences have value in that they provide information that could be used in planning longitudinal
The examination of the chronology of self-care acquisition allows a preliminary, although fragmentary,
analysis of the relationship of the development of hand
use to the development of self-care. We do not know
when these self-care skills reach adult levels of efciency
and precision, but clearly skill acquisition is a gradual
process that extends into the preteens. It appears that
aspects of hand skill acquisition over the years include
(a) nger manipulation and grip ability, (b) the use of
two hands in a complementary fashion, (c) the ability
to use the hands in varied positions with and without
vision, (d) the execution of increasingly complex action
sequences, and (e) the development of automaticity.
These hand skills have been discussed in the preceding
section in relation to specic skills and are summarized
in the following.
Automaticity
Self-care literature provides a clue to the development
of automaticity in skill performance. There appears to
be a delay following a childs ability to perform a skill
in eating and dressing before the skill can be performed
while carrying on a conversation (Hurlock, 1964;
Klein, 1983). This suggests that an automatic level of
214
SUMMARY
This chapter has focused on how and when typical
children learn the separate skills and subskills of selfcare. Knowledge of the sequences in which typical
children acquire self-sufciency in daily activities can be
valuable in understanding the roadblocks for children
with physical or mental disability, and sequences of skill
acquisition can provide guidance in selecting the level
of skill at which to introduce training. However, the
acquisition of self-care in typical children provides only
a part of the picture needed for treatment planning. We
must learn how skills are learned in the presence of
different disabilities. We know that the presence of a
specic disability can change the sequence in which a
child will master self-care skills, but we have little information about what that sequence is.
Most of our knowledge about the impact of disability on specic self-care skills comes from therapeutic
accounts. Several recent publications have provided
detailed task analyses of methods of dressing, eating,
and hygiene keyed to different impairments and
include multiple suggestions for adaptations. Some of
these are designed for children (e.g., Case Smith, 2000;
Shepard, 2001), and others for adults (e.g., Backman
& Christiansen, 2000; Holm, Rogers, & James, 1998;
Snell & Vogtle, 2000).
The tables also provide useful knowledge about the
acquisition of part skills. Typically children do not learn
a skill all at once. Rather they are encouraged to do
what they can long before they are developmentally
ready to master a skill. Parents of children with disabilities should be encouraged to introduce part-skill
practice early and to set expectations that their child do
whatever he can. This will take more time but it will
contribute to the childs sense of mastery and selfesteem and provide practice of the motor skill. It would
be helpful to know more about the factors affecting
such a learning process and the differences and
similarities in the ways in which children with disabilities learn complex skills.
REFERENCES
Amato PR, Ochiltree G (1986). Children becoming
independent: An investigation of childrens performance
of practical life-skills. Australian Journal of Psychology,
38(1):5968.
American Occupational Therapy Association (1994).
Uniform terminology for occupational therapy, 3rd ed.
American Journal of Occupational Therapy,
48:10471054.
American Psychiatric Association (1994). Diagnostic and
Statistical Manual IV (4th ed.). Washington, DC, Author.
Backman C, Christiansen CH (2000). Assessment of selfcare performance. In C Christiansen, editor: Ways of
living: Self-care strategies for special needs (pp. 2944).
Bethesda, MD, American Occupational Therapy
Association.
Bleck EE, Nagel DA (1975). Physically handicapped
children: A medical atlas for teachers. New York, Grune &
Stratton.
Bott EA, Blatz WE, Chant N, Bott H (1928). Observation
and training of fundamental habits in young children.
Genetic Psychology Monograph, 4:1161.
Brigance AH (1978). Diagnostic inventory of early
development. North Billerica, MA, Curriculum Associates.
Bullock M, Lutkenhaus P (1988). The development of
volitional behavior in the toddler years. Child
Development, 59:664674.
Carruth BR, Skinner JD (2002). Feeding behaviors and
other motor development in healthy children (224
months). Journal of the American College of Nutrition,
21(2):8889.
Case-Smith J (2000). Self-care strategies for children with
developmental disabilities. In C Christiansen, editor: Ways
of living: Self-care strategies for special needs (pp. 81121).
216
Chapter
11
THE DEVELOPMENT OF
GRAPHOMOTOR SKILLS
Jenny Ziviani Margaret Wallen
CHAPTER OUTLINE
GENERAL GRAPHOMOTOR COMPETENCY
Acquisition of Graphomotor Skills
Implement Grasp and Manipulation
DRAWING
The Nature of Drawing
Computers and Drawing
Drawing and Developmental Evaluation
HANDWRITING
Handwriting and Writing: Complementary Concepts
The Developmental Nature of Handwriting
Factors Contributing to Handwriting Performance
Computers and Handwriting
SUMMARY
letters, gures, or other signicant symbols, predominantly on paper. Both these activities can be used to
record experiences or thoughts, as well as communicate
these to others. Drawing and handwriting are complex motor behaviors in which psychomotor, linguistic,
and biomechanical processes interact with maturational, developmental, and learning processes (SmitsEngelsman & Van Galen, 1997). The need to develop
prociency in activities as fundamental as drawing and
handwriting may be questioned in relation to the
growing reliance on electronic communication devices.
It is the position of this chapter that graphomotor skills
represent more than a means of recording thoughts or
conveying experiences. Developmentally these skills
allow for experimentation and self-expression in the
way a child interacts with the environment. Furthermore they are a means by which children learn basic
tool use and are able to produce a product that is
socially recognized and rewarded. As such they form an
important part of the development of an individual.
GENERAL GRAPHOMOTOR
COMPETENCY
ACQUISITION OF G RAPHOMOTOR SKILLS
Children, when presented with tools for inscription,
readily smear paint, scribble with crayons, or draw. The
nature of the inscription varies depending on the
developmental status of individuals and their motor
learning in relation to prior exposure to graphomotor
experiences. In its most basic form simple inscription
with an implement onto a page can be understood as a
perceptual-motor act (van Galen, 1991). The learning
of a skilled task such as handwriting or drawing,
217
218
Task
Sensory
perception
Cognition
Motor control
Affective state
Motor planning
Biomechanical
considerations
Demands of
task (cognitive,
attentional,
linguistic)
Nature of task
(copied,
self-generated,
creative,
academic)
Speed and
accuracy
Skilled
manipulative task
Skilled
Handwriting
Environment
Writing materials
(implements,
paper)
Furniture
Ambient
features
(temperature,
lighting, noise)
Expectations of
others
Exposure to
instruction and
practice
Motor Learning
Handwriting and drawing have been conceptualized as
learned motor tasks. Motor learning theorists explain
the control of coordinated movement in terms of openand closed-loop systems (Mathiowetz & Bass-Haugen,
2002; McGill, 1998). The closed-loop system involves
afferent feedback. In the case of handwriting, feedback
is received from the pressures exerted on the writing
implement and the writing surface, from the senses of
touch and movement in the ngers, hand, and arm,
and from visually monitoring written work. This afferent feedback is used to update the nervous system
about the accuracy of the handwriting. The feedback is
Grasps
Many children acquire a dynamic tripod grip by about
612 years of age as their means of implement manipulation for drawing and handwriting. Children progress
through a range of precursor gripspalmar, incomplete tripod (or palmar supinate), and static tripod
before adopting the dynamic tripod grip (Dennis &
Swinth, 2001; Rosenbloom & Horton, 1971; Saida &
Miyashita, 1979). Schneck and Henderson (1990)
propose a 10-grip scale to classify the developmental
range of grasps. Level 1, or the lowest level of the scale,
220
Writing Implements
A further issue related to implement manipulation is
the nature or type of writing tool used. Traditionally
young writers are given lead pencils with a larger than
normal lead and barrel for drawing and handwriting
instruction. This practice is based on the premise that it
is easier for their small hands to hold and manipulate a
larger barrel. However, studies have demonstrated that
the legibility of kindergarten childrens handwriting is
not associated with the tool used (Oehler et al., 2000).
The maturity of grasp employed, nevertheless, may
vary with the specic tool used (Yakimishyn & MagillEvans, 2002).
DRAWING
THE NATURE OF DRAWING
When considering drawing, the simple copying of
shapes and gures should be differentiated from the
creation of pictures from memory or imagination. The
present discussion is concerned primarily with copying
skills (the perceptual-motor elements of drawing).
Certain characteristics are thought to distinguish
younger childrens drawings from those of adults.
Childrens drawings have been described as being
formula-like and depicting subjects as they are
perceived to be rather than how they look (Freeman,
1980). Apart from exceptional children (Selfe, 1985),
most children in their preschool and early school years
construct their drawings from simple geometric forms
and do not compose broad outlines that are then
detailed. Fenson (1985), in a detailed longitudinal
study of one child, found that a fundamental shift
occurred between 3 and 7 years of age in the structure
of drawing. The child moved from a constructional
style to the use of contoured forms.
The term constructional in this context relates to the
assembling of simple geometric forms into a pictorial
representation (e.g., the use of a circle for a face and a
rectangle for a body when drawing a person). The term
contoured, on the other hand, refers to the sketching
of an outline, which is subsequently detailed to achieve
the desired representation. Although no attempt is
made to explain why a shift might occur from the
former to the latter, it is postulated that the motivation
is a quest for realism. This quest, in conjunction with
greater skill in visually controlling actions and the
ability to plan spatially and execute actions, constitutes
the move from a juvenile to a more adult approach to
drawing. Obviously such assumptions require further
investigation.
There has been little advance on the seminal work of
authors such as Luquet (1927) and Kellogg (1969)
when considering the maturation of childrens drawings. These authors considered that children between
the ages of 2 and 3 years make scribbling marks on
paper with no representational intent. The fascination
is thought to be more with the process of experimentation and exploration of media than with an intended
product. The drawing by a 212-year-old child in Figure
11-2 demonstrates how repetitious marks (in this case
Figure 11-2
the way they are in an adult reality. Figure 11-5 demonstrates how a 6-year-old girl perceives her school. The
drawing is not a realistic representation but it does
contain features of her school and it highlights her
understanding of a friendly environment. Finally, from
around 8 years of age the child begins to take into
account visual perspective; object position and orientation also become more important. This shift represents
a progression from intellectual realism, in which the
child draws what he or she knows about a stimulus, to
a stage in which the drawing depicts what actually can
be seen (Laws & Lawrence, 2001). This shift also has
been associated with an increase in the amount of
attention given to the object being drawn (Sutton &
Rose, 1998), suggesting that realism is based on ability
to attend to detail.
The ability to produce and appreciate graphic perspective has received considerable attention (Freeman,
1980; Freeman, Eiser, & Sayers, 1977; Nicholls &
Kennedy, 1992; Toomela, 1999). Some authors see the
onset of perspective as evidence of cognitive maturation
(Reid & Shefeld, 1990), whereas others argue that it
is necessary to learn the rules about how to represent
something in true perspective (Hagen, 1985; Orde,
1997). This latter view is based on studies that found
little difference between the way in which children
handle the three-dimensional plane and the methods
adopted by adults. In both populations, individuals
who have no special artistic talent or training reproduce
the visual structures that they see in natural perspective
along a continuum from orthogonal (no diminishing
222
Rain
Big tree
Horse float
Horse 1 Baby in
back seat
Jeep
Driver
Road
Figure 11-3
Figure 11-4
Figure 11-5
Figure 11-6
224
BUS A OW E N
JENNY MARK
226
HANDWRITING
HANDWRITING AND WRITING:
COMPLEMENTARY CONCEPTS
There is an important differentiation, but also relationship, between handwriting and writing. Handwriting
refers to the process of transcribing letters to form
words and words to form sentences. Writing, on the
other hand, is the composition and content of the
material that is handwritten. Procient writing relies
on well-developed handwriting skills. Jones and
Christensen (1999), for instance, reported that
handwriting skills accounted for 50% of the variance in
the quality of writing content in a sample of 6- and 7year-old students. Both handwriting and writing are
complex abilities that are acquired hand-in-hand with
childrens acquisition of language. As with drawing, the
foundations for both handwriting and writing are the
integration of intrinsic and extrinsic factors. Extrinsic
factors involved in handwriting include instruction in
handwriting, the quality and extent of practice undertaken, the requirements of the task, and the materials
used. Intrinsic abilities include orthographic coding,
orthographic-motor integration, visual-motor skills, ne
motor skills, cognition, linguistic skills, and motivation
(Tseng & Chow, 2000). Orthographic coding involves
developing a visual representation of letters and words,
knowledge of the process of forming each letter, a
verbal label for each letter, an accurate representation
of the letters form in memory and the ability to access
and retrieve this information from memory (Edwards,
2003; Jones & Christensen, 1999; Weintraub &
Graham, 2000). Orthographic-motor integration is the
way in which this letter knowledge can be motorically
transcribed to form letters and words on paper. Writers
who have poor orthographic coding and ortho-motor
integration, and thus need to attend to the mechanics
of handwriting (e.g., letter formation, spacing, alignment), have less attention and working memory that
can be directed to composing written work and spelling,
monitoring, and revision of the written work (Edwards,
2003; Swanson & Berninger, 1996).
Childrens competence in writing depends, in part,
on the mastery of handwriting (Graham, Harris, &
Fink, 2000). The ability to write legibly and in a timely
fashion is necessary for children to adequately document their knowledge and learning. Childrens documentation is largely the basis on which their knowledge
acquisition is judged. Research has shown that lower
BOX 11-1
1.
2.
3.
4.
5.
6.
7.
8.
9.
Vertical line
Horizontal line
Circle
Cross
Right oblique line
Square
Left oblique line
Oblique cross
Triangle
because it is faster than exclusively manuscript or cursive. Mixed handwriting that is predominantly cursive is
used relatively less frequently than other forms (cursive,
manuscript, or mixed but mostly manuscript). Despite
this, mixed handwriting that is mostly cursive tends to
yield more legible handwriting (Graham, 1998).
Integral to the issues of handwriting development
and understanding the developmental expectations for
handwriting is the question of when young children are
ready to begin handwriting instruction. A number of
factors may be considered here: perceptual readiness,
linguistic readiness, and the maturity of pencil control.
Beery (1989) argued that young children are not ready
to learn handwriting until they can correctly copy the
rst nine forms of the VMI (Beery, 1989) (Box 11-1).
Kindergarten children who can copy these forms also
can copy signicantly more letters (Daly, Kelly, &
Krauss, 2003; Weil & Cunningham Amundson, 1994)
and have better handwriting in grade 1 (Marr &
Cermak, 2002) than children who cannot achieve nine
forms. Daly demonstrated that 56% of children, when
tested in the rst quarter of the kindergarten school
year, were able to copy these nine forms. This compares
with 88% who copied the nine forms in the middle of
the kindergarten school year in Weil and Cunningham
Amundsons study. Thus if using the VMI as an indicator of handwriting readiness, most typically developing kindergarten children should be ready to succeed
with handwriting instruction in the latter half of the
kindergarten school year.
As children develop the skill of handwriting, their
performance changes both qualitatively and quantitatively. Handwriting quality and quantity translate, respectively, into legibility and speed. How do we judge if
either or both of these aspects are appropriate for the
228
Table 11-1
Author
Groff (1961)
School Grade
5
6
35.1
40.6
49.6
25
37
47
57
35
46
54
66
62
64
54.2
57.1
63.8
80.7
94.2
32.6
34.2
38.4
46.1
52.1
Working Memory
Swanson and Berninger (1996) demonstrated that
individuals have a unique working memory. Working
memory is the ability to temporarily retain information
during the processing of other information. During
handwriting, orthographic codes are retrieved from
long-term memory and held in working memory while
the writer is developing the text (Weintraub & Graham,
2000). More processing functions are available for idea
generation, translation, and sequencing of ideas to text,
and revision of writing when aspects of handwriting
(including orthographic skills and even punctuation)
are automatic (Jones & Christensen, 1999). Further,
ideas that are held in working memory may be lost if a
child needs to focus attention on the mechanics of
forming a letter (Graham et al., 2001). Evidence for
this derives from studies that have shown a relationship
between orthographic-motor integration and written
expression and have demonstrated that writing (written
Handwriting Instruction
Handwriting is heavily influenced by the nature of the
instruction received and the extent of practice undertaken by the individual. In fact, the main factor that
influenced legibility in a study by Lamme and Ayris
(1983) was the great variability in handwriting instruction provided by the teachers involved in the study.
Handwriting probably receives insufcient emphasis in
school curricula: Teachers (62% of sample) reported
that they would like to spend more classroom time on
handwriting instruction (Hammerschmidt & Sudsawad,
2004). Berninger and co-workers (1997) surveyed
teachers who reported that students were becoming
less procient at handwriting when they reached year 1
than students of previous years.
The importance of focused handwriting instruction
to both legible handwriting and writing has been
demonstrated in a number of studies (Berninger et al.,
1997; Graham et al., 2000; Jones & Christensen,
1999; Jongmans et al., 2003; Karlsdottir, 1996). Important components to include in handwriting instruction are listed in Box 11-2 (Berninger et al., 1997;
Graham et al., 2000; Hayes, 1982; Jones & Christensen,
1999). It seems that providing more types of cues or
perceptual prompting of letter formation may result in
better outcomes.
Adi-Japha and Freeman (2001) found that by 6
years of age childrens writing and drawing systems
were differentiated. Children as young as 3 years of age
produce different scribbles when asked to write their
name than those scribbles generated when drawing a
picture (Haney, 2002). Writing-specic cortical routes
emerge probably as a result of practicing handwriting.
Writing within a script context (e.g., words and letters
on a page) rather than writing within a picture context
produced more fluent handwriting (Adi-Japha &
Freeman, 2001). The importance of handwriting practice in early learners and thus a differentiation and
specialization of writing is reinforced by these ndings.
Further, consideration needs to be given to the teaching and practice of handwriting within writing specic
contexts; that is, using dedicated writing implements
and books, and reducing drawing conditions when the
aim is handwriting prociency. Working within a script
context activates the writing system, and activation of
230
BOX 11-2
(2000) found that nger function was a strong predictor of good or poor handwriting ability. Rather than
reflecting strictly ne motor ability, the nger function
tasks contained largely proprioceptive and somatosensory ability. Yochman and Parush (1998), however,
found no correlation between kinesthesia-related tests
and handwriting performance.
Visual motor integration appears to be an important
factor in handwriting legibility. A great deal of research
supports the assumptions that (a) visual motor integration is correlated with handwriting performance in
good, as well as poor handwriters (Tseng & Chow,
2000; Tseng & Murray, 1994; Weil & Cunningham
Amundson, 1994); (b) visual motor abilities are weaker
in children with handwriting difculties, across a wide
range of ages, compared with children without handwriting difculties (Cornhill & Case-Smith, 1996; Daly,
Kelly, & Krauss, 2003; Rubin & Henderson, 1982;
Tseng & Chow, 2000; Tseng & Murray, 1994); and
(c) visual motor integration difculties are a predictor
of handwriting legibility (Cornhill & Case-Smith, 1996;
Maeland, 1992; Tseng & Chow, 2000; Weintraub &
Graham, 2000; Yochman & Parush, 1998). Visual motor
integration may be particularly important in the acquisition of handwriting because visual motor abilities are
used to acquire orthographic coding skills. Occupational
therapists tend to view visual motor integration as underlying handwriting dysfunction and intervene using visual
motor activities (Case-Smith, 2002). Despite this relative
abundance of evidence conrming the relationships
between visual motor integration and handwriting,
there is as yet no evidence that remediating visual
motor skills will result in enhanced handwriting output.
Handwriting intervention studies in the educational
and motor learning literature focus on developing
orthographic coding and using self-instruction methods
for enhancing handwriting legibility and writing ability
(Berninger et al., 1997; Graham et al., 2000; Hayes,
1982; Jones & Christensen, 1999; Jongmans et al., 2003;
Karlsdottir, 1996). These studies provide good evidence
that these approaches are effective in enhancing various
aspects of handwriting legibility and speed and also the
content of written work. Studies in occupational therapy
are fewer in number than studies in education. Typically
occupational therapy intervention studies integrate
multiple theoretical perspectives and offer broad-based
interventions encompassing biomechanical, multisensory,
visual motor, ne motor, and handwriting-specic interventions (Case-Smith, 2002; Lockhart & Law, 1994;
Peterson & Nelson, 2003). A range of outcomes which
are not always related to handwriting legibility, speed, and
content are evaluated. Two such broad-based studies
(including one randomized controlled trial) reported
signicant improvement in handwriting; however, the
specic components of the intervention that contributed
232
SUMMARY
The process and products of childrens drawing and
handwriting have intrigued occupational therapists, as
well as others interested in child development, for a
number of years. It is clear from this chapter that,
although we now have certain structures in place to
understand the developmental transitions in childrens
drawings, there is still much to understand. The same
can be said for handwriting. There remain aspects of
drawing and handwriting acquisition that still tantalize;
this chapter concludes by pointing to some issues that
still beg investigation.
Drawing is an important developmental experience
for children. With the increasing use of computers by
younger and younger children, some of the pencil and
paper drawings with which we are most familiar are
being accomplished using a computer. Are we able to
translate our knowledge of paper-based outcomes to
those on the screen?
Preliminary research has indicated that handwriting
and keyboarding have differing underlying components. Thus we are unlikely to be able to translate our
knowledge of handwriting directly to keyboarding. A
greater understanding of word processing, as an
alternative form of recording work, is necessary to
match it to the individual needs of students. Using a
motor learning framework, we understand that handwriting is a learned motor task requiring interplay
among the writer, the task, and the environment. A key
environmental factor in its acquisition is the quality of
instruction received and amount of practice undertaken. However, even in the presence of adequate
instruction there are a multitude of factors pertinent to
an individual that may affect the childs ability to
develop handwriting. The association between some
of these factors and handwriting has been better
researched than others. For example, we know there is
an association between visual motor integration and
handwriting. We are less certain of the relationship
between other factors such as kinesthesia and in-hand
manipulation and handwriting. Cognitive, linguistic,
and motivation factors also should inform research in
this eld. We require a better understanding of the
REFERENCES
Adi-Japha E, Freeman NH (2001). Development of
differentiation between writing and drawing systems.
Developmental Psychology, 27(9):101114.
Alston J (1985). The handwriting of 7- to 9-year-olds.
British Journal of Special Education, 12:6872.
Amundson SJ (1995). Evaluation Tool of Childrens
Handwriting. Homer, AK, OT Kids.
234
236
Chapter
12
CHAPTER OUTLINE
FRAMEWORKS FOR INTERVENTION WITH
CHILDREN WHO HAVE HAND SKILL PROBLEMS
Impact of Hand Skill Problems on Childrens
Occupational Performance
Intervention Approaches: Modifications or
Adaptations and Motor Skill Remediation
Factors to Consider in Intervention Planning
GOAL SETTING FOR HAND SKILL INTERVENTION
Considerations in Setting Goals
Short-Term Goals for Hand Skill Intervention
RESEARCH RELATED TO HAND SKILL INTERVENTION
INTERVENTION STRATEGIES FOR HAND SKILL
PROBLEMS
Positioning of the Child and the Therapist
Tactile or Sensory Awareness or Discrimination
Tone and Postural or Proximal Control
Isolated Arm and Hand Movements
Grasp
Voluntary Release
In-Hand Manipulation
Bilateral Hand Skills
Integration of Skills into Occupational Performance
ADJUNCTS TO DIRECT INTERVENTION: SPLINTING,
CASTING, AND CONSTRAINT-INDUCED
MOVEMENT THERAPY
Splinting
Casting
Constraint-Induced Movement Therapy
SUMMARY
FRAMEWORKS FOR
INTERVENTION WITH CHILDREN
WHO HAVE HAND SKILL
PROBLEMS
I MPACT OF HAND SKILL PROBLEMS ON
C HILDRENS OCCUPATIONAL PERFORMANCE
Hand function has great signicance for occupational
performance. The greater the difculties with hand
function, the greater the impairment in skills that allow
for independence and participation in academic and
social activities. Children with hand function difculties
usually are limited in their ability to effectively or efciently complete daily life skills and develop skills that
will support optimal occupational performance in the
future. In addition, for some children even subtle difculties with hand skills may affect their social participation because of limitations in ability to engage in activities
with their peers or messiness in task completion.
Fine motor skills have a major impact on childrens
school performance. McHale and Cermak (1992)
found that all the classrooms observed [in their study]
had a high level of ne motor demands, with ne
motor tasks being carried out for 30% to 60% of the
classroom day and the majority of these tasks involving
writing activities. In preschool settings, children must
be able to manage the classroom manipulatives,
including puzzles, scissors, crayons, blocks, pegs, and
beads. Elementary school-age children must be able to
manage the entire writing process, which includes
handling a pencil or pen effectively, using an eraser,
tearing and folding paper, putting paper into notebooks and folders, and doing art projects. As children
239
240
reach middle school and high school age, they not only
have a high volume of written work, but they also take
courses that have labs (e.g., science, industrial arts,
home economics) that require the ability to handle
small materials with dexterity.
Children of all ages need effective hand function to
manage eating, dressing, hygiene care, and a variety of
other self-care activities independently in multiple environments. Expectations for independence, and therefore procient hand use, increase throughout adolescence.
Chapter 10 provides a thorough summary of the interaction of hand and self-care skills.
In response to the frequent difculties that children
show and the impact of these difculties on occupational performance, pediatric occupational therapists
typically address childrens hand skills. Swart et al.
(1997) report that intervention for ne motor skills is
a top occupational therapy priority in working with
children. In their study of approximately 200 pediatric
occupational therapists, intervention for ne motor
issues was rated as very important or important by
100% of the therapists. Almost 100% of these therapists
reported that they consistently or often provide services
that address ne motor issues, and at least 90% reported
that addressing ne motor issues is unique or very unique
to the profession of occupational therapy.
I NTERVENTION APPROACHES:
MODIFICATIONS OR ADAPTATIONS AND
MOTOR SKILL REMEDIATION
A childs hand function difculties always must be
placed within the context of the childs overall functioning, needs, and priorities. Despite the signicance
of hand skills to occupational performance and social
participation, the decision about intervention for hand
skill difculties must be made with the child (when
feasible) and the family or other key individuals,
keeping in mind the childs overall needs and priorities
and the likelihood of intervention having a signicant
impact on the childs functioning. For example, a child
may have multiple need areas for intervention, such as
academic skills, mental health issues, or language difculties. In addition, within the scope of responsibilities
of the occupational therapist, issues of hand function
may be of lesser priority than other areas, such as sensory regulatory issues, acquisition of independence in
life skills, or psychosocial concerns.
Thus the occupational therapist participates with the
child, the family, and other team members in determining if and when intervention with a focus on hand
function issues is in the best interest of the child. Two
general types of intervention approaches may be considered in addressing hand function issues: adaptations
242
engagement in occupation is viewed as the overarching outcome of the occupational therapy process (p. 615).
244
BOX 12-1
BOX 12-2
1.
2.
3.
4.
5.
6.
7.
8.
9.
246
BOX 12-3
Children often nd it easier to work on a new movement component (a) in isolation from other movement
components, (b) when not handling objects, or (c) when
handling well-stabilized objects as compared with using
the movement component within an activity that has
objects that are not stabilized.
For example, supination and pronation, wrist flexion
and extension, and MP flexion and extension with IP
extension may be addressed by playing a game with the
child in which the child is tapping the table, or his or
her leg, or a drum and is only using the desired upper
extremity motion. The therapist may assist the child to
stabilize a more proximal body part (e.g., the humerus
if using supination or pronation, the forearm if using
wrist extension or flexion, the dorsum of the hand if
using MP flexion or extension). The therapist also may
assist the child with actively using internal rotation,
pronation, and wrist flexion, because even children
who tend to hold their arms in these patterns have
functional difculty using active internal rotation,
pronation, and wrist flexion. They need assistance in
developing control over the movements, as well as
assistance in holding in a more externally rotated or
extended or slightly supinated position.
Supination is a particularly difcult movement component for children with abnormal tone. Even children
with only slightly low tone tend to stabilize in full
pronation when engaging in ne motor tasks. Full
pronation is functional for palmar grasp patterns, but
use of pronation when precision grasp patterns or
object manipulation are needed interferes signicantly
with thumb mobility and distal nger control. Being
able to hold various degrees of supination is critical for
higher-level hand skills. Full supination is helpful in
performing activities, but the most important range of
supination for functional skill use is between full
pronation and midposition. The ability to hold at any
point within this range is important. During most skills
that involve controlled use of the radial ngers and
thumb, the forearm is in approximately 30 to 45 degrees
of supination.
248
G RASP
250
252
nger flexion necessary (and the degree of differentiation in radial-ulnar nger positions) is less; gradually
the size of this object may be reduced. Similarly, the
size of the objects grasped with the radial ngers and
thumb may be decreased as the childs prociency
increases.
The therapist also may consider carefully selecting or
modifying the diameter and shape of objects to be held
with a power grasp. Tools with thin or rounded handles
are more difcult for the child to grasp well; children
with instability may grasp handles that are slightly
larger in diameter or have ridges or indentations more
effectively. Also the degree of power needed within the
activity should be graded because increased demands
for power tend to cause the child to move from a more
rened power grasp pattern to a palmar grasp pattern.
After grasping an object, the child may use the
object to complete a task (e.g., use a hammer to pound
a nail), use in-hand manipulation to adjust the object
after grasp (e.g., turn a key to t it into a lock), or
254
VOLUNTARY RELEASE
Motor control problems with voluntary release typically
result from three key areas of difculty: (a) poor arm
stability; (b) increased flexor tone, which causes sting
or difculty with grasp using the nger surface; and
(c) lack of effective use of the intrinsics. In the latter
case, problems are seen in poor IP joint extension or
poor MP joint control. A typical pattern seen in poorquality voluntary release is MP joint extension with or
without IP joint extension. Problems with stability and
lack of extensor activity appropriately balanced with flexor
activity interfere with the effectiveness and efciency of
voluntary release. Some children with these problems
resort to using tenodesis action by flexing at the wrist
to initiate the voluntary release (and may use the same
pattern to initiate grasp).
Arm instability is often a key contributor to voluntary release problems in children with involuntary movement or tremors. However, instability also may negatively
affect voluntary release in children with low or high
tone who do not have excess movement. For effective
voluntary release the child needs to release where and
when he or she wants to do so. The arm is important
in transporting the hand to the location for release.
Holding the arm in a stable position during hand
opening contributes to accurate timing of the release.
Several strategies may be used with children who
have stability problems that affect voluntary release.
Upper extremity weight bearing, particularly on
extended arms, may help the child to develop improved
cocontraction at the scapulohumeral area, elbow, and
wrist. Reaching activities that involve touching a
desired target and holding that position for a few
seconds also may be helpful, particularly if the reaching
is done in a variety of planes of movement. For the
child who has marked instability or needs to function
despite some instability, teaching the child to stabilize
the arm against the body or on a surface before opening the hand may be a helpful compensatory strategy.
Many of the stability problems that affect voluntary
release are related to problems with wrist stability
during nger extension; stabilizing in wrist extension
allows nger extension without using tenodesis action
and supports accuracy of release. Some children show
wrist flexion during elbow flexion, but they are able to
voluntarily release with the wrist in extension if the
elbow is extended. For these children, and even those
who have signicant flexor tone at the wrist and ngers
when the elbow is flexed, an effective strategy can be to
facilitate releasing objects away from midline and with
the elbow extended. As with the strategy discussed for
I N-HAND MANIPULATION
In-hand manipulation skills seem to be the most complex of all ne motor skills. In-hand manipulation
involves the adjustment of objects by movements of the
ngers so that the objects are more appropriately placed
within the hand for the task to be accomplished (Exner,
1990a, 1992). In-hand manipulation occurs within one
hand. Five basic types of in-hand manipulation skills
have been described (Box 12-4) (Exner, 1992).
Each of the in-hand manipulation skills may occur
with no other object in the hand at the time of the
manipulation or while the ulnar ngers are holding one
or more objects in the center or ulnar side of the palm
(Exner, 1990a, 1992). When other objects are held in
the hand during manipulation, the skill has the term
added with stabilization.
Although almost any child with a disability that affects
motor or sensory functioning has difculty with inhand manipulation skills, not all of these children are
candidates for intervention for in-hand manipulation
problems. To be considered for intervention specically
for in-hand manipulation problems, the child needs
to have:
Index nger isolation
Good skills in basic grasp and release patterns
including the ability to grasp a variety of objects and
to accommodate the hands to these objects effectively. The child needs to be able to grasp objects at
least on the nger surface, not only use a palmar
grasp.
BOX 12-4
256
Figure 12-8 A. Use of palm-to-nger translation may be encouraged by grading the activity. Initially the object is placed
on the distal surface of the childs radial ngers. B. Gradually the object is placed more proximally on the childs nger
surface. C. After success with more proximal placement, the child may be able to use palm-to-nger translation when the
therapist places the object in the palm of the childs hand.
258
C
Figure 12-9 A. The child is forming a picture with a set
of puzzle books. He is encouraged to nd the side of the
block that ts the design being constructed. The therapist
has placed the correct side of the block against the palm
of his hand so that he must use complex rotation to nd
it. B. Before using the in-hand manipulation skill of
complex rotation, the child must use palm-to-nger
translation to move the block toward the distal nger
surface. In that process the block begins to be turned.
C. Having identied the correct side, the child shifts the
object out of the pads of the ngers before placement
with the other blocks. (From Case-Smith, J [2005].
Occupational Therapy for Children, 5th ed. St Louis, Mosby.)
260
262
ADJUNCTS TO DIRECT
INTERVENTION: SPLINTING,
CASTING, AND CONSTRAINTINDUCED MOVEMENT THERAPY
Using splinting or casting with children requires careful
attention to precautions associated with these devices.
Children may have less ability to report discomfort or
changes in tone or function associated with the splint
or other device, so preparation of the parent or guardian
for use of the device and key factors to observe is important. Initially, close monitoring of the childs status
with the device is needed, thus leading to scheduling of
frequent check-up sessions with opportunities to gather
feedback from the parent or guardian and the child
about the device and its impact on the childs arm or
hand, their comfort, and their functioning.
SPLINTING
Hand splinting can be an effective adjunct to direct
intervention for hand skills in children. Exner (2005)
provides information about splinting in children,
including a description of precautions and a summary
of the various types of splints and their rationale.
Additional information about splint types, and their
uses and construction is provided by Gabriel and
Duvall-Riley (2000) and Chapter 18. Research on the
use of splinting in children is limited. In a research
literature review analysis by Teplicky, Law, and Russell
(2002) on the use of upper extremity splinting and
CASTING
Upper extremity casting for decreasing tone and
improving hand function has been used in intervention
with children with signicant disabilities. Studies by
Yasukawa (1992); Law et al. (1991); Tona and Schneck
(1993); and Copley, Watson-Will, and Dent (1996)
have shown some empiric support for this approach. A
study by Law and associates (1997) used group experimental methodology to study the effect of occupational
therapy treatment without casting to an intervention
program that included casting. In this study, the benets
of including casting were not evident. Although
changes may occur in tone or range of motion as a
result of casting, changes in occupational performance
may not (Russell & Law, 2003).
SUMMARY
Intervention for children with hand skill problems is
guided by use of the occupational therapy framework,
in which the overarching factor is the childs ability to
engage in occupational tasks with greater skill and thus
more effectively fulll desired roles. In approaching this
intervention, many factors must be considered. The
therapistin collaboration with the child (whenever
feasible), parent or guardian, teacher, and signicant
otherscarefully assesses the childs strengths and
264
REFERENCES
Barnes KJ (1986). Improving prehension skills of children
with cerebral palsy: A clinical study. Occupational Therapy
Journal of Research, 6:227240.
Barnes KJ (1989a). Relationship of upper extremity weight
bearing to hand skills of boys with cerebral palsy.
Occupational Therapy Journal of Research, 9:143154.
Barnes KJ (1989b). Direct replication: Relationship of
upper extremity weight bearing to hand skills of boys with
cerebral palsy. Occupational Therapy Journal of Research,
9:235242.
Beckung E, Steffenburg U, Uvebrant P (1997). Motor and
sensory dysfunctions in children with mental retardation
and epilepsy. Seizure, 6:4350.
Boehme R (1988). Improving upper body control: An
approach to assessment and treatment of tonal dysfunction.
Tucson, AZ, Therapy Skill Builders.
Bumin G, Kayihan H (2001). Effectiveness of two different
sensory integration programmes for children with spastic
diplegic cerebral palsy. Disability and Rehabilitation,
23(9):394399.
Case-Smith J (1991). The effects of tactile defensiveness
and tactile discrimination on in-hand manipulation. The
American Journal of Occupational Therapy, 45:811818.
Case-Smith J (2000). Effects of occupational therapy
services on ne motor and functional performance in
preschool children. The American Journal of
Occupational Therapy, 54(4):373380.
Case-Smith J, Fisher AG, Bauer D (1989). An analysis of
the relationship between proximal and distal motor
control, The American Journal of Occupational Therapy,
43:657662.
Copley J, Watson-Will A, Dent K (1996). Upper limb
casting for clients with cerebral palsy: A clinical report.
Australian Occupational Therapy Journal, 43:3950.
Croce R, DePaepe J (1989). A critique of therapeutic
intervention programming with reference to an alternative
approach based on motor learning theory. Physical and
Occupational Therapy in Pediatrics, 9(3):533.
Crocker MD, MacKay-Lyons M, McDonnell E (1997).
Forced use of the upper extremity in cerebral palsy: A
single case design. The American Journal of Occupational
Therapy, 5:824833.
Cronin AF (2004). Mothering a child with hidden
impairments. The American Journal of Occupational
Therapy, 58(1):8392.
Curry J, Exner C (1988). Comparison of tactile preferences
in children with and without cerebral palsy. The American
Journal of Occupational Therapy, 42(6):371377.
DeGangi GA, Wietlisbach S, Goodin M, Scheiner N (1993).
A comparison of structured sensorimotor therapy and
child-centered activity in the treatment of preschool
children with sensorimotor problems. The American
Journal of Occupational Therapy, 47:777786.
DeLuca SC, Echols K, Ramey SL, Taub E (2003). Pediatric
constraint-induced movement therapy for a young child
with cerebral palsy: Two episodes of care. Journal of the
American Physical Therapy Association, 83:10031013.
Eliasson AC, Gordon AM (2000). Impaired force
coordination during object release in children with
hemiplegic cerebral palsy. Developmental Medicine and
Child Neurology, 42:228234.
Erhardt R (1992). Eye-hand coordination. In J Case-Smith,
C Pehoski, editors: Development of hand skills in the child.
266
Chapter
13
CHAPTER OUTLINE
VERTICAL SURFACES
MANIPULATIVES
The Manipulatives Program
Fine Motor Planning
SCISSORS
DRAWING AND WRITING
Hand Preference
Activities to Help Develop Pencil Grasp and Control
WHAT MAKES THERAPY EFFECTIVE?
CASE STUDY
The occupation of the preschool child is to be independent and successful in all of the areas of the
classroom and playground, both with play activities as
well as with self-care. Specically in respect to ne
267
268
the most surprising nding [in the study] was that the
therapists use of play and peer interaction predicted the ne
motor outcomes and that among the intervention variables, play
and peer interaction were the only signicant predictors
(p. 378).
VERTICAL SURFACES
Vertical and slant board surfaces are an extremely
important part of the ne motor program. Benbow
(1995) emphasized the importance of working on a
vertical surface to encourage appropriate hand and
wrist position for ne motor and handwriting skills.
Both vertical and slant board surfaces correctly position
the wrist in extension, which supports thumb abduction so that the thumb can work skillfully with the
ngertips. Stable wrist extension and thumb opposition
also facilitate total arching of the hand for skillful
manipulation of objects. Therefore, providing a vertical
or slant board work surface is an important modication that parents and teachers can incorporate as they
work or play with the child.
Activities performed above eye level on vertical or
near-vertical work surfaces such as floor and table easels
promote
as well as the development of arm and shoulder muscles. Whenever possible, teachers are encouraged to
provide activity areas in which the children are working
upright (sitting, kneeling, or standing) with their arms
and hands moving against gravity at an easel or other
vertical work surface, rather than leaning over small
tables. When children work on a horizontal surface,
270
MANIPULATIVES
Young children, especially 3-year-olds, should spend
more time with ne motor manipulatives than writing
utensils. Sometimes parents and teachers feel that
young children should begin to practice with pencils
and markers, but this early practice may result in a poor
pencil grasp, partially because children may be asked
to use writing utensils before their hands are ready for
that kind of rened activity. Benbow (1995) specically
noted that boys tend to avoid ne motor activities in
lieu of computer games, while girls who practice with
writing implements at an early age
without proper adult attention or supervision may then
adopt pencil grips that are inefcient or even harmful (p. 255).
Wake Up Hands
Wake Up Hands activities provide sensory stimulation
to the hands, including tactile stimulation as well as
proprioceptive/kinesthetic stimulation, resulting in
overall readiness for later activities. A wide variety of
soft objects, including gel-lled balls, rubber animals,
and countless other items are used during Wake Up
Hands. Activities include squeezing the objects, rolling
them on the table, rolling them all over the hands (with
each hand taking turns), grabbing them with the
thumb and index nger (pincer grasp), poking them
with either the thumb or index nger, and using them
isometrically by having both hands press the object.
Students also perform a variety of motions with their
hands such as clapping, rubbing, or shaking. A variety
of textures might be provided through materials such
as unscented lotion, powder (including dry Jell-O
powder), and fabrics from rough to smooth. The
therapists also provide rubber bands or elastic sewn
into circles of various sizes so that students can perform
a variety of pulling activities, one nger at a time.
Students seem to particularly enjoy placing the rubber
band in a way that traps their ngers, and they enjoy
moving their ngers against the resistance while pretending to escape from the rubber band trap. TheraBand and Thera tubing also can be used for pulling and
stretching activities during Wake Up Hands.
One of the most popular Wake Up Hands activities
is the accordion tubes, sometimes called rapper
snappers. These tubes provide excellent resistance to
nger, arm, and shoulder muscles when students
expand the tubes, and provide similar input when they
are manually contracted to become small again (Figure
13-3). During a game, the tubes can be called caterpillars; therapists ask students to pretend they are
turning baby caterpillars into big ones, and then back
into babies. For a whole-body motion that provides an
excellent motor break before a tabletop session,
students pair up and connect their accordion tubes.
They then make the caterpillars pop by pulling, tug
of war style, on their respective tubes until the tubes
come apart with a large popping sound. From a safety
perspective, be sure that the students have enough
space for this activity, as some of the smaller students
literally fall backward from the momentum until they
Figure 13-3
Figure 13-4
tube toys.
272
Strong Hands
Although activities from any of the three components
of a therapy session may address multiple areas of
development, the rationale for labeling the activity is to
help students understand its primary goal. The use of
these specic terms has provided unexpected benets,
particularly the use of the term Strong Hands. The
students with less than average hand grasp strength
are often the students who are least likely to take risks
with novel ne motor tasks. When Strong Hands is
1. Play Dough
a. Use a garlic press to make spaghetti.
b. Use rolling pins to make pretend cookies
(shoulder and arm strength).
c. Press cookie cutters into flattened play dough.
d. Find hidden objects such as pegs, marbles, or
toys.
Note: Crayola Model Magic or clay also can be used,
depending on how much resistance is desired.
Homemade play dough provides less resistance than
the commercial variety.
2. Water sprayers (e.g., those found in a drug store for
spritzing hair)
a. Spray water onto pictures drawn with markers to
make them melt. (Note: This activity works
best if the markers are relatively new and the
drawing has just been completed.)
b. Spray a mixture of water and food coloring to
color snow (in northern climates).
c. Spray plants or outdoor bushes.
d. Spray the walls while in the bathtub, with the
shower curtain partially closed.
3. Geoboards: This is a grid of nails or plastic points.
Use rubber bands of varying thicknesses to create
designs, or use nylon potholder loops for less resistance. (Cotton cloth loops often are too thick to
successfully stay on the points.)
4. Newspapers: Tear newspapers to stuff a scarecrow or
other classroom project.
5. Wringing out sponges or washcloths (e.g., as part of
a clean-up activity, or in the bathtub).
6. Squeeze toys such as the Swinging Monkey and the
Flying Fist (see Appendix for sources).
Smart Hands
Smart Hands manipulative activities typically emphasize multiple skills within one activity. For example,
using a wind-up toy encourages isolated use of the
thumb and index nger, but may also require a signicant amount of nger strength, depending on the
resistance of the particular wind-up toy and on the
shape of the winding knob or key. It is important for
therapists to be familiar enough with their manipulatives to know which ones are appropriate for 3-yearolds, and which ones are more appropriate for 4- or
5-year-olds. Classroom teachers often need guidance
about this as well. Some of the classroom building
manipulatives require more eye-hand coordination
than is expected for the typical 3-year-old, and if
teachers expect and encourage students to participate
in a too-demanding activity, students may begin to feel
that they are not successful with manipulatives.
When referring specically to in-hand manipulation,
Case-Smith (1995) stated that
274
Figure 13-5
for lacing.
Figure 13-6
Figure 13-7
Baubles)
Figure 13-9
upper left).
c.
d.
Figure 13-8
e.
f.
276
Figure 13-10
Figure 13-12
Figure 13-11
278
Figure 13-13
SCISSORS
When scissors are held correctly, and when they t a
childs hand well, cutting activities exercise the same
intrinsic muscles that are needed to manipulate a pencil
in a mature tripod grasp. The correct scissors position
is with the thumb and middle nger in the handles of
the scissors, the index nger on the outside of the
handle to stabilize, and ngers four and ve curled into
the palm. The lower handle of the scissors should rest
on the distal joint of the middle nger, and the upper
handle of the scissors should rest on the distal joint of
the thumb (Figure 13-14). The tips of the scissors
should be pointing away from the child, and the wrist
of the cutting hand should be in extension (Benbow,
1995). When cutting, movements of the ngers should
be in the intermediate range of excursion between very
flexed and very extended to use the intrinsic muscles to
their maximum benet (Benbow, 1990a,b).
Many children hold scissors with the thumb and
index nger in the handles. This position does not
allow for proper control of the scissors, and does not
help develop the hand for ne motor skill. When
scissors are held in this manner, the scissors movements
are performed primarily by the larger muscles of the
forearm rather than primarily by the intrinsics
(Benbow, 1990a,b). Parents and teachers can make a
tremendous difference in a childs hand development
simply by teaching the proper scissors grasp. It is
necessary to check throughout the year to be sure
children continue to use the correct grasp because in
the early stages of learning the habit can be lost.
The best scissors for children have sharp blades,
blunt tips, and small-holed handles. In recent years the
trend for childrens scissors has been for the handles to
be formed in such a way that they actually discourage
the use of the correct scissors grasp. Rather than have
children use scissors in their skill ngers, the design of
these scissors encourages children to place all four
ngers in the handles and keep their index nger on the
inside of the lower handle (Figure 13-15). The near-
Figure 13-14
280
BOX 13-3
Figure 13-16
Tripod grasp.
HAND PREFERENCE
The strongly academic nature of the kindergarten
curriculum in the surrounding community dictates that
students are more comfortable and successful in
kindergarten if they have developed adequate skill for
drawing, writing, and scissors use for at least one hand.
This means that it is useful to know which of a childs
hands is signicantly more skilled. For most students,
282
BOX 13-4
Developmental Hierarchy to
Follow When Teaching Students
to Write Their Name
284
286
CASE STUDY
Tim became a student in an integrated preschool classroom
at the Newton Early Childhood Program in the middle of
winter, as he had just turned three years old and was eligible
for services from the public schools. He had been given a
diagnosis of PDD-NOS, with the primary referring concerns including immaturities in his language development,
social skills, play skills, reduced eye contact, and apparent
unresponsiveness when he was called by name. Before
entering the program, Tim had been receiving services from
Early Intervention, including physical therapy, OT, speech
and language therapy, home visits, applied behavioral
analysis, floor time, and a center-based toddler group.
Specic difculties noted by his two Early Intervention
occupational therapists included heightened sensitivity to
tactile inputs, avoidance of vestibular-based activities, overall low muscle tone, and immature ne motor skills.
When Tim became a student in the integrated classroom,
all of the preceding difculties were noted, although he
presented as a student with signicantly reduced attention
rather than as a student with PDD-NOS. The OT evaluation that was completed during Tims rst few weeks of
school indicated that although he had hyperextensibility in
his ngers and reduced ne motor skill (both eyehand
coordination and grasp patterns), his most signicant ne
motor problem was his difculty intuiting motor plans for
using manipulatives. At that time Tim showed a preference
for his right hand, but used both hands fairly interchangeably, which is not unusual for a 3-year-old. When picking up
small objects, Tim tended to use a whole-hand pattern
(raking) rather than the expected pincer grasp. He would
even hold the tip of a lacing string in the palm of his hand
rather than with his ngertips. Tim also showed immaturities with puzzles and copying designs, so it was
recommended that visual perceptual skills also be included
in his educational and treatment plan. Tim was referred for
OT to address ne motor skills, visual perceptual skills, and
sensory integration difculties.
The treatment notes from Tims rst OT ne motor
session indicate that the session was only 15 minutes long,
which was the maximum length of time he was able to
participate in structured tabletop tasks. Only ve activities
could be presented during that rst session. Instead of using
a top with a stem for twirling, Tim used a stemless top that
simply required a brush of the hand to make it spin. He also
used the Flying Fist toy (the child squeezes the base to make
the top portion, the hand, pop off), at which point it
became clear that his overall hand strength also was reduced
for his age. His rst stringing activity was placing the
medium rings (12-inch) onto gimp, which was difcult for
him. He did not spontaneously seem to understand that he
should place his ngers close to the tip of the gimp; rather,
he held far back on the gimp, which made it impossible for
the tip to be inserted into the ring. (Like Tim, many young
students need cues to hold close to the tip of the string.)
CASE STUDYCONTD
motor immaturities. At that point his ne motor planning
difculties were considered to be mild, although still
present. His ability to generalize motor plans among similar
manipulatives had signicantly improved over his rst year
of preschool.
With the use of a 20-degree slant board surface, largediameter markers (no crayons), and gentle but consistent
reminders about using the correct pencil grasp, Tim made
the transition to using a static tripod grasp, and nally
developed the beginnings of a mature tripod grasp as he
began to rest his hand on the table more consistently. Two
years after entering the program, at 5 years of age Tim
nally established the consistent use of his right hand for
drawing and scissors use. He would occasionally forget and
place scissors in his left hand, but after starting to cut he
would realize that the scissors were on the incorrect hand
and switch them on his own. With markers, he was consistent about using his right hand. His ability to write his
name gradually changed from being an arm and wrist skill
with the letters lling up an entire page, to being a nger
skill. By February of that year, he was able to sign his
Valentines with the letters of his name only 12 inch high.
Tim worked his way through the more difcult levels of
the ne motor skills curriculum, including buttoning activities and multistep manipulatives. His hand grasp strength
continued to test at the level of a child approximately 1 year
younger than his chronological age of 5, although he was
able to open and close all of the containers expected for
a child his age, and could turn the knobs on even the
most resistive of the wind-up toys used in the treatment
sessions. Fine motor planning difculties were rarely seen,
and when they appeared Tim was able to learn a new motor
task with only minimal verbal cueing, and no physical
assistance.
Interestingly, the primary area of difculty for Tim
during the last few months before he entered kindergarten
was in the area of representative drawing. He had learned to
draw recognizable, visually organized drawings of people,
but had not been able to create any other kinds of representative drawings on his own, particularly multiple component
drawings. He had difculty forming a visual plan for a
drawing, although he could easily label all the components
that might belong in the drawing (his verbal skills had
reached age level by this time). He was able to draw a red
circle on the paper for an apple, but was not able to make
the drawing more complex by adding a stem or leaf, and
certainly not an entire tree. After Tim was helped to learn
how to draw basic shapes and incorporate them into
gradually more complex drawings, he was able to make a
small variety of multicomponent representative drawings by
the end of the year (5 years, 4 months of age). Many
students are able to learn these skills within the classroom
setting, with the occupational therapist working naturalistically in the classroom, but in Tims case it was necessary
to remove him to a separate, nondistractible room for the
OT sessions for the second half of his last year of preschool.
Two typically developing peers were brought along as
models so the sessions would seem more like a regular
school tabletop activity.
By the end of the year, Tim had achieved nearly all of the
objectives on the Newton Early Childhood Fine Motor
and Visual Perceptual Inventory for Children Entering
Kindergarten, (Broder, 2004) with the only signicant area
of weakness being that he still needed to improve his overall
control of drawing implements. (The pre-kindergarten
inventory can be found in Appendix 13 B.) His major areas
of improvement over the 212 years that he received OT
within an integrated preschool setting were in the establishment of a consistent hand preference for writing and
cutting, improvements in ne motor planning, major
improvements in ne motor skills including cutting, and
good progress in pencil control, as well as visual motor
activities such as representative drawing and design copying.
It was recommended that Tim continue with OT services in
kindergarten, primarily to address his continued needs with
pencil control and representative drawing ability.
ACKNOWLEDGMENTS
REFERENCES
288
Appendix
FINGER PLAYS
Finger Frolics, revised, by Cromwell, Hibner, and Faitel
(Partner Press, available online at www.ghbooks.com)
is a good source for nger plays on a variety of different
themes. Some of the most useful nger plays from this
13A
289
290
Appendix
13B
Therapist: ______________________
______Skillfully uses a variety of multiple-step manipulatives (e.g., buttoning, wind-up toys, eye droppers).
______Laces using a skilled grasp.
______Builds a block tower of at least 10 one-inch blocks.
______Uses two hands together skillfully for bilateral activities.
______Demonstrates a clear right or left hand preference.
______Uses non-dominant hand appropriately as an assist (e.g., stabilizes paper while drawing).
______Holds primary-sized (large diameter) drawing implements with a skilled grasp.
______Draws and colors using skilled movement: forearm, wrist, ngers (most skilled).
______Draws or colors for ve minutes with good endurance, pressure, speed, and accuracy.
______Draws a recognizable person with at least 8 body parts.
______Draws recognizable pictures with multiple components (e.g., a sun, tree, house).
______Copies horizontal and vertical lines, a plus, and a square.
______Copies right and left diagonal lines, and a triangle.
______Connects dots or completes simple mazes, and draws the lines with control.
______Prints letters of rst name.
______Independently completes age-appropriate 5-10 piece interlocking puzzles.
______Positions preschool scissors on hand with skilled grasp, given one reminder.
______Cuts on a line smoothly and accurately, sustaining rhythm.
______Independently cuts out a square, triangle, and a circle shape, using appropriate strategies (e.g., turning
paper so that scissors stay pointing away from body).
3 = Achieved
290
Chapter
14
EVALUATION OF HANDWRITING
Scott D. Tomchek Colleen M. Schneck
CHAPTER OUTLINE
PRE-EVALUATION DATA COLLECTION
Writing Samples
Interviews
Record Review
EVALUATION OF RELATED PERFORMANCE
COMPONENTS
Neuromuscular and Neurodevelopmental Status
Visual Perception
Motor Performance
Formulation of Written Language
Sensory Processing
ACTUAL EVALUATION OF HANDWRITING
PERFORMANCE
Domains of Handwriting
Legibility Components
Writing Speed
Ergonomic Factors
Keyboarding Performance
Commercially Available Assessment Tools
SUMMARY
291
292
PRE-EVALUATION DATA
COLLECTION
components could be used to predict scores in handwriting performance. This information can guide therapists in their evaluation of children based on teacher
report of poor handwriting.
Two factors that teachers indicated most frequently
as important for handwriting to be acceptable were
correct letter formation, and directionality and proper
spacing (Hammerschmidt & Sudsawad, 2004). The
most important criteria that teachers used to determine
whether or not a student was having handwriting difculties was their not being able to read the students
writing. The majority of teachers answered that the
methods they used to evaluate their students handwriting was comparing student handwriting to classroom peers (37%), followed by comparing student
handwriting to models in a book (35%). This awareness
can help structure the content of the occupational
therapy evaluation and ensure that occupational therapy
assessments produce results that are relevant to the
childrens handwriting function in the classroom.
The parents can provide insight on many of these
same factors as the child accomplishes handwriting in
the home. In addition, the parents can provide information unknown to the teacher such as the attitudes
and interests of the child. This difference in perspective
may be useful in identifying the causes of handwriting
difculties.
I NTERVIEWS
RECORD REVIEW
Reviewing the childs educational le can provide information on past academic performance and any special
services that may have been provided to the student.
Information obtained from the educational le may
reveal a pattern of educational difculty or isolated
ndings that may be useful in the assessment of handwriting difculties. This review of information also may
require further interview of the teacher.
Through classroom observations, examination of
work samples, interviews, and record review a therapist
is able to identify related performance components and
administer assessments designed to determine whether
decits in the identied components exist and to what
extent (Admundson & Weil, 1996).
WRITING SAMPLES
EVALUATION OF RELATED
PERFORMANCE COMPONENTS
To assist in the process of identifying the cause(s) of
the handwriting impairments in a student, analysis of
the underlying performance components related to
handwriting require evaluation. Here, underlying sta-
N EUROMUSCULAR AND
N EURODEVELOPMENTAL STATUS
A comprehensive neuromuscular assessment often
initiates the physical evaluation. Active and passive
range of motion limitations are noted and if present,
may limit in-hand or upper extremity mobility necessary for handwriting. Muscle tone in the trunk and
extremities (both proximally and distally) also is evaluated. Strength often is assessed through structured
observation of antigravity postures and movements.
Specic muscle testing may be necessary in the hands
and upper extremities.
To supplement neuromuscular ndings, a neurodevelopmental assessment may be conducted. The
neurodevelopmental assessment should include two
groups of automated responses as markers for motor
dysfunction. The rst group of automated responses
to be evaluated is the primitive reflexes. These reflexes
appear during the late gestational period, are present at
birth, and normally are suppressed by higher cortical
function by approximately 6 months. Delayed integration of these reflexes has an impact on dissociated head
and extremity movements and thus affects motor performance. For example, delayed integration of the
asymmetric tonic neck reflex may limit dissociated head
and upper extremity movement to the point of affecting development of hand dominance and midline crossing of the upper extremities. After evaluation of the
primitive reflexes, the second group of automated
responses to be evaluated is the postural reactions.
Righting, equilibrium, and protective reactions must be
evaluated. The coordination of these reactions into
functional balance often is observed during free play
and independent movements. Decreased functional
balance in sitting may limit independent arm movement from trunk movement for writing. The child then
moves the trunk with the arm for writing or frequently
re-positions the paper as arm movement is needed.
Together, the tone, strength, reflex integration, and
balance development of a child serve as the foundation
for the development of stability and stable movement
patterns. If a child is posturally unstable she or he will
likely use compensatory movement patterns, which in
turn may affect motor control during handwriting
tasks. For example, a child who exhibits instability in
the upper trunk and shoulder may use a mid-guard
posture or stabilize at the shoulder to stabilize his or
her upper thoracic and cervical areas during handwriting. By doing so, the childs fluidity and speed of
VISUAL PERCEPTION
Visual perception is the ability to use visual information
to recognize, recall, discriminate, and make meaning
out of what we see. Visual perceptual areas include the
visual receptive (acuity, convergence, tracking) and the
visual cognitive, which include visual discrimination,
visual memory, visual form constancy, visual spatial relation, visual sequential memory, visual gure ground,
and visual closure. Together, these perceptual skills
provide vital information that is used and relied on by
many other systems for optimal functioning. For
instance, when copying text from a blackboard, we use
visual gure ground to select the appropriate text on
the blackboard to copy, visual discrimination to differentiate among letters, and visual memory and sequential memory to recall the text to be copied; therefore it
is important to distinguish visual perceptual problems
from motor problems.
Visual-perceptual skills, including visual-spatial
retrieval and left-right orientation, enable children to
distinguish visually among graphic forms and judge
their correctness (Solvik, 1975; Thomassen & Teulings,
1983). Tseng and Murray (1994) reported that the
143 children in their sample of children with illegible
handwriting had low scores on perceptual-motor
measures. Tseng and Chow (2002) found a signicant
difference between slow and normal handwriters in
upper-limb coordination, visual memory, spatial relation, form constancy, visual sequential memory, gureground, visual motor integration, and sustained
attention.
Clinical observations can be used to obtain some
informal information of perceptual abilities in children
who cannot participate in formal testing. Situations can
be devised to assess specic areas or a childs work can
be evaluated. For instance, having a child nd a certain
toy in a toy box can assess visual gure ground. Asking
a child to nd or select an item he or she was shown
could be used to assess visual memory. Spatial relation
difculties often can be seen when asking a child to
accomplish writing tasks, because drawings, letters, or
words may be rotated. In addition, alignment and
spacing may be a problem.
Visual discrimination difculties may affect the childs
handwriting in several ways and can be evaluated
through observation of the child during handwriting.
294
MOTOR PERFORMANCE
For the purpose of this section, assessment of motor
function is divided into the three broad areas of gross,
ne, and visual motor development. There is much
overlap between these areas of motor performance, in
that common performance components (i.e., muscle
tone, strength, coordination, visual motor integration)
serve as the foundation for skilled motor output. There
is also signicant reliance between these motor skill
areas. For example, stability aspects of gross motor development are vital in ne motor performance because
stability provides a solid foundation from which skilled
upper extremity usage is achieved. Both formal and
structured observation assessment is described here.
Some formalized assessments used to assess gross, ne,
Table 14-1
Instrument
Author, Year
Ages
Areas Assessed
Hammill, Pearson,
and Voress, 1993
49 years
Eye-hand coordination
Spatial relations
Figure ground
Visual-motor speed
Copying
Position in space
Visual closure
Form constancy
411 years
Visual discrimination
Visual memory
Visual spatial relations
Visual gure ground
Visual closure
Gardner, 1995
412.11 years
Visual
Visual
Visual
Visual
Visual
Visual
Visual
Gardner, 1997
1218 years
Visual discrimination
Visual memory
Visual form constancy
Visual spatial relation
Visual sequential memory
Visual gure ground
Visual closure
discrimination
memory
form constancy
spatial relation
sequential memory
gure ground
closure
296
Table 14-2
Instrument
Author, Year
Ages
Areas Assessed
Peabody Developmental
Motor Scales-Second Edition
(PDMS-2)
Birth83 months
Birth47 months
Bruininks-Oseretsky Test of
Motor Prociency
Bruininks, 1978
4.514.5 years
Ulrich, 2000
310 years
Gross motor:
Reflexes
Stationary
Locomotor
Object manipulation
Fine motor:
Grasping
Visual-motor integration
Mobility
Motor organization
Stability
Functional performance
Social/emotional abilities
Gross motor:
Running speed and agility
Balance
Bilateral coordination
Strength
Upper-limb coordination
Fine motor:
Response speed
Visual-motor control
Upper-limb speed and
dexterity
Locomotor
Object control
Gardner, 1995
313.11 years
Gardner, 1992
1240 years
215 years
balance also have application to the vestibular processing of a child, illustrating the link between sensory and
motor responses.
Assessment of these gross motor areas often is
done within the context of play-based assessment or
strictly through observation. Having a child go
through a simple obstacle course, for instance, can provide a wealth of information about balance, strength,
and postural control. Further, within many clinic
settings or natural environments a child has the opportunity to explore his or her environment. In doing so,
the child likely ambulates, runs, jumps, or has to climb
steps. Situations also can be developed to observe catch
and throw abilities. Report of functioning during
higher-level bilateral motor tasks such as riding a bike
and swimming likely may be obtained from the
298
Table 14-3
Foundation Area
Specic Observations
Hand dominance
Can the child isolate nger motions for prehension of smaller objects?
What grasp pattern does the child use to hold a pencil?
Does the child use this grasp statically or dynamically?
Does the child hold the pencil rmly?
Does the quality of the childs grasp and prehension abilities differ when they are
just manipulating an object in comparison to when they are manipulating a tool for
use (i.e., hammer, pencil, ball)?
Does the child have adequate hand strength to hold onto objects?
Manipulation skill
Does the child frequently shift his or her position while interacting with an object?
Does the child frequently turn or reposition a task?
If so, is he or she doing so to avoid midline crossing or for visual inspection?
Ergonomic factors
Table 14-4
SENSORY PROCESSING
Sensory processing is a broad term that refers to the
way in which the central and peripheral nervous
systems manage incoming sensory information from
the senses (Lane, Miller, & Hanft, 2000). Basically,
sensory processing refers to the sequence of events that
occurs as we take in and respond to environmental
stimulation. In the assessment of handwritingin addi-
Instrument
Author, Year
Ages
Areas Assessed
Carrow-Woolfolk, 1995
321.11 years
Use of conventions
Use of linguistic forms
Communicate meaningfully
410 years
Basic writing
Contextual writing
Spontaneous formats
Contextual conventions
Contextual language
Story construction
Contrived formats
Style
Spelling
Vocabulary
Logical sentences
Sentence combining
McGhee, Bryant,
Larson, and Rivera,
1995
6.614.11 years
Ideation
Semantics
Syntax
Capitalization
Punctuation
Spelling
Composition/essay
818 years
Warden and
Hutchinson, 1992
Grades 212
Purpose/focus
Audience
Vocabulary
Style/tone
Support/development
Organization
Sentence structure/variety
Grammar/usage
Capitalization
Spelling
7.617.11 years
300
ACTUAL EVALUATION OF
HANDWRITING PERFORMANCE
The process of gathering information for a comprehensive handwriting evaluation has already largely been
completed through observations made during previous
testing. Specically, observations about hand dominance, midline crossing, grasp patterns to a pencil, the
rmness of that grasp, and the amount of pressure to
paper have all been made during the ne and visual
motor assessment. In addition, observations about
stability and compensatory movement patterns also
have been made. In this section, the focus is on the
actual process of handwriting. Initially the domains of
handwriting, legibility components, speed of writing,
and ergonomic factors are discussed as outlined by
Amundson (1992, 2001), followed by a discussion of
commercially available assessment tools.
DOMAINS OF HANDWRITING
Evaluating the various domains of handwriting allows
the therapist to identify which tasks the child is having
more difculty with and address those tasks in the
intervention plan (Amundson, 1992). Handwriting
skills needed by students are included in Box 14-1.
LEGIBILITY COMPONENTS
Legibility decits in handwriting are often the primary
reason for referral for handwriting problems. These
BOX 14-1
WRITING SPEED
Coupled with legibility, writing speed is a cornerstone
of functional handwriting (Amundson, 1995). In
general, speed of handwriting decreases as the complexity of a task increases. Therefore speed of writing
needs to be addressed within each of the domains of
handwriting to determine the impact of the different
task demands. Although speed for copying tasks may be
adequate, slower handwriting speed for composition
task may indicate coexisting formulation decits.
Slow handwriting speed affects functional performance because it prevents students from meeting time
constraints involved in schoolwork (Cermak, 1991;
Levine et al., 1981). Slow hand writers are different in
the way they process written information from normal
speed writers. Slow hand writers depend on visual
processing, whereas normal speed writers are motor
based (Tseng & Chow, 2002). Slow hand writers were
poorer as a group than children with normal-speed
hand writers in graphomotor output, level of perceptual motor skills, and decreased attention (Tseng &
Chow, 2000). Rosenblum, Parush, and Weiss (2003)
using a computerized digital system found that nonprocient 8- to 9-year-old handwriters required signicantly more time to perform handwriting tasks and
that their in air time, was especially longer as compared to the procient handwriters. In air time refers
to pauses, or temporary halts in the flow of writing
(Benbow, 1995; Kaminsky & Powers, 1981). The
researchers found this phenomenon not as a pause
but rather as a motion tour taking place in the air
between the writing of successive characters, segments,
letters, and words. It may be that the in air time
helps the student to prepare to execute subsequent
characters or character segments. This time may be
needed to parameratize the motor program or initiate
activity in the muscle groups needed to execute the
character. In addition, the researchers found that the
nonprocient hand writers handwriting speed was
slower and they wrote fewer characters per minute.
Formal assessments of handwriting speed are
included in Table 14-5.
E RGONOMIC FACTORS
The ergonomic factors affecting handwriting (e.g.,
writing posture, grip, stability) have been discussed
in the related performance components section, but
require further mention here. From the literature,
writing tools, paper, and surfaces appear to be important factors in handwriting.
In assessing grip it is important to keep in mind the
effects of the task and writing tool on the grasp.
No. 2
No. 2
No. 2
Pencil:
X
X
X
X
X
X
X
X
X
X
X
Grades 1-6
Paper:
Lined
Unlined
810.11 yrs
Script Assessed:
Manuscript
Cursive
58.11 years
No. 2
X
X
X
X
X
X
X
X
X
Grades 1-6
ETCHCursive
ETCH
Manuscript
THS
Manuscript
THSCursive
Domains Tested:
Near-point copying
Far-point copying
Composition
Dictation
Upper or lower case
Manuscript to cursive
Sensorimotor
Test Type:
Norm-referenced
Criterion-referenced
Minnesota
Handwriting
Assessment
(MHA)
(Reisman, 1999)
Age/grade Range:
Table 14-5
No. 2
Grades 3-8
Childrens Handwriting
Evaluation Scale (CHES)
(Phelps & Stempel,
1984)
302
Part III Therapeutic Intervention
Psychological Corp
Available:
Percent Accurate
X
F, Sp, Sz, A
15-30 minutes
10-20 minutes
OT Kids
Percent Accurate
X
F, Sp, Sz, A
15-30 minutes
10-20 minutes
Quality Rating Key: L=legibility, F=form, A=alignment, Sz=size, Sp=spacing, Sl=slant, R=rhythm, Ap=appearance
Scores Yielded Key: PR=percentile rank, Std=standard score, Sc=scaled score, St=stanine
X
Sp, A, Sz, F
15-20 minutes
15-20 minutes
Validated:
Test-retest
Intrarater
Classication/Rating
Scores Yielded:
Reliability:
Interrater
X
Sp, A, Sz, F
X
L, F, A, Sz, Sp
Assessed:
Rate
Quality (types)
15-20 minutes
15-20 minutes
ETCHCursive
ETCH
Manuscript
THS
Manuscript
THSCursive
2.5 minutes
3-7 minutes
Minnesota
Handwriting
Assessment
(MHA)
(Reisman, 1999)
Time:
Administration
Scoring
Table 14-5
Author
Continued
Std, PR
X
F, Sl, R, Sp, Ap
2 minutes
3-7 minutes
Childrens Handwriting
Evaluation Scale (CHES)
(Phelps & Stempel,
1984)
Script Assessed:
Manuscript
Cursive
X
No. 2
2 minutes
3-7 minutes
Paper:
Lined
Unlined
Pencil:
Time:
Administration
Scoring
No. 2
X
X
X
X
X
Test Type:
Norm-referenced
Criterion-referenced
Age/grade Range:
Domains Tested:
Near-point copying
Far-point copying
Composition
Dictation
Upper or lower case
Manuscript to cursive
Sensorimotor
Grades 3-8
CHESManuscript
(Phelps, 1987)
Table 14-5
3 minutes
2 minutes
No. 2
X
X
3-12 years
Handwriting
Speed Test
(Wallen et al,
1996a)
X
X
7-18.5 years
Test of Legible
Handwriting
(Larsen &
Hammill, 1989)
3 minutes
2 minutes
No. 2
Grades 2-6
304
Part III Therapeutic Intervention
Quality Rating Key: L=legibility, F=form, A=alignment, Sz=size, Sp=spacing, Sl=slant, R=rhythm, Ap=appearance
Scores Yielded Key: Pr=percentile rank, Std=standard score, Sc=scaled score, St=stanine
Author
Available:
Out of print
On 1292 Australian
students
Std
Handwriting
Speed Test
(Wallen et al,
1996a)
Validated:
Test-retest
Intrarater
Pr
Std, Pr
Scores Yielded:
Reliability:
Interrater
X
F, Sp, R, Ap
CHESManuscript
(Phelps, 1987)
Denver Handwriting
Analysis (Anderson,
1983)
Assessed:
Rate
Quality (types)
Table 14-5
Out of print
Std, Pr
Test of Legible
Handwriting
(Larsen &
Hammill, 1989)
Author
On 1525 Chinese
students
Reported to be 0.98
Reported to be 0.95
Std, Pr
306
KEYBOARDING PERFORMANCE
Sixth-grade students demonstrated low to moderate
correlation between keyboarding and handwriting performance (Rogers & Case-Smith, 2002). This suggests
that these forms of written expression require distinctly
different skills. Most students who were slow at handwriting or had poor legibility increased the quantity
and overall legibility of the text they produced with a
keyboard. This suggests that it is important to assess
keyboarding in nonprocient writers because it may
simplify their text production. It may allow certain
children to concentrate on content and meaning when
composing and encourage them to engage in compositional writing.
COMMERCIALLY AVAILABLE
ASSESSMENT TOOLS
Several handwriting assessment tools are commercially
available. Although Table 14-5 provides a graphic summary of these instruments, Appendix 14A also provides
an in-depth analysis of each of the instruments that is
still currently available and summarizes some ndings.
As can be seen by analyzing Appendix 14A, few
quality instruments specically designed to assess handwriting are available. Selecting the most appropriate
instrument is dependent on the individual needs of the
evaluating therapist. In selecting a handwriting instrument, therapists must not only consider a childs area
of handwriting difculty, but also the psychometric
SUMMARY
As can be seen by this discussion, the assessment of
handwriting difculty is a complex multifaceted
process. Administration of a formalized assessment of
handwriting alone does not provide the information
necessary to determine the root of the difculty or
effectively plan a program. Stability, visual perception,
motor performance, written language, and sensory
processing aspects of development serve as the foundations for developing the skill of handwriting. Thus
although administration of a formalized assessment of
handwriting can determine the nature of handwriting
difculty demonstrated by a child, assessment of the
related performance components provides the basis for
determining the potential cause(s) of the impairments.
Identication of these causes allows appropriate
intervention planning to develop remediation of the
handwriting impairments.
REFERENCES
Alston J, Taylor J (1987). Handwriting: Theory, research,
and practice. Worcester, MA, Billings.
Amundson SJ (1992). Handwriting: Evaluation and
intervention in school settings. In J Case-Smith, C
Pehoski, editors: Development of hand skills in the child.
Rockville, MD, American Occupational Therapy
Association.
Amundson SJ (1995). Evaluation Tool of Childrens
Handwriting. Homer, AK, OT Kids.
Amundson, SJ (2001). Prewriting and handwriting skills. In
J Case-Smith, editor: Occupational therapy for children,
4th ed. St. Louis, Mosby.
308
Appendix
14A
HANDWRITING ASSESSMENT
INSTRUMENTS
MINNESOTA HANDWRITING
ASSESSMENT
AUTHOR, YEAR
PURPOSE
Reisman, 1999
DESCRIPTION
The Minnesota Handwriting Assessment (MHA) is
used to assess manuscript and DNealian handwriting
in rst and second graders who have knowledge of the
English language. The MHA assesses Rate for the whole
writing sample and ve quality categories for each letter
of the sample: Legibility, Form, Alignment, Size, and
Spacing. Subjective quality ratings are collected and
yield interpretive cutoff scores within each category:
Performing like peers (top 75% of the nal sample),
performing somewhat below peers (within the bottom
5% and 25% of the nal sample), or performing well
below peers (bottom 5% of the nal sample). It is recommended that students performing somewhat below
peers should be monitored to determine if ongoing
instruction or practice is needed or whether the student
is demonstrating delayed development of underlying
hand skills. It is recommended that students performing in the well-below-peers category be referred for
comprehensive evaluation to determine the cause of
handwriting difculties.
CONTENTS
What does the schedule try to measure? The MHA assesses
handwriting performance. Specically measured are
Rate for the whole writing sample and ve quality
ASSESSMENT COMPONENTS
Type of Assessment: Near-point copy assessment
Task(s): The student is required to copy from a printed
stimulus sheet onto lines below the words the
brown jumped lazy fox quick dogs over. The mixed
word order of the sentence is used to reduce the
speed and memory advantage of better readers by
requiring all students to refer to the stimulus items
word by word.
Paper Type: Supplied lined paper with center dotted
line
Pencil Type: Any size pencil typically used by the student
311
312
PARTICIPANTS
Children: First and second graders
Developmental Level: Grade level
DERIVATION
Writing sample and scoring criteria were developed
from a pilot version, through literature review and eld
testing with revision.
PUBLISHED MATERIAL
Author/Others: author (Reisman, 1993, 1999); others
(Peterson, 1999)
Usefulness: The MHA was designed to help meet the
needs of many school districts and special education
departments that require a handwriting assessment
to support the teachers subjective judgment of poor
quality or slow rate (Reisman, 1999).
Validated: On 2000 rst- and second-grade students
from a nationwide sample (Reisman, 1993, 1999)
with cutoff scores determined after analysis. Content
validity was established in development.
Reliability: Interrater ranged from 0.77 to 0.88
(Pearson) for inexperienced raters and from 0.90 to
0.99 for experienced raters. Intrarater reliability (5to 7-day interval) ranged from 0.96 to 1. Test-retest
stability (5- to 7-day interval) for performance level
ranged from 64% to 86%. Test-retest reliability was
conducted in a related study (Peterson, 1999) with
at-risk students with correlations ranging from 0.60
to 0.89 (Internal Consistency Coefcient ICC).
Additional Statistical Analysis: A special group study
was conducted to examine rst- and second-grade
students in regular education, special education, and
special education plus occupational therapy. Scores
on the MHA and Test of Visual Motor Skills (a
design copying visual motor control test) were
compared with correlations ranging from 0.37
(second grade) to 0.89 (occupational therapy).
REFERENCES
Ottenbacher KJ, Tomchek SD (1993). Reliability
analysis in therapeutic research: Practice and procedures. American Journal of Occupational Therapy,
47(1):1016.
Ottenbacher KJ, Tomchek SD (1994). Measurement
error in method comparison studies: An empirical
examination. Archives of Physical Medicine &
Rehabilitation, 75(5):505512.
Peterson CQ (1999). The effect of an occupational
therapy intervention handwriting in academically atrisk rst graders. Unpublished doctoral dissertation.
Cincinnati, The Union Institute Graduate School.
Reisman JE (1993). Development and reliability of the
research version of the Minnesota Handwriting Test.
Physical and Occupational Therapy in Pediatrics,
13:4155.
Reisman JE (1999). Minnesota handwriting assessment.
Los Angeles, Psychological Corporation.
DESCRIPTION
The Test of Handwriting Skills (THS) is used to assess
a childs neurosensory integration ability in handwriting either manuscript or cursive and in upper and
lower case forms, and to measure the speed with which
a child handwrites from: writing from memory, upper
and lower case letters of the alphabet in sequence;
writing from dictation, upper and lower case letters of
the alphabet out of sequence; writing from dictation,
numbers out of numeric sequence; copying selected
letters from the alphabet; copying selected words; copying selected sentences; and writing from dictation
selected words. Although the purpose of the THS is to
measure how a child (ages 5 years, 0 months to 10
years, 11 months) can write letters, words, and numbers spontaneously, from dictation, or from copying, it
is also used to determine the speed by which a child can
produce letters spontaneously. Each of the 206 letters
in the sample is scored using a four-point scale. The
THS provides normative data in 3-month increments
for each subtest (standard scores, scaled scores, percentile ranks, and stanines).
CONTENTS
PARTICIPANTS
What does the schedule try to measure? The THS measures quality of handwriting in children. In addition
to the 206 scorable-language symbols, the THS,
Manuscript version (for children ages 5 years to 8
years 11 months) has reversal of letters, letters touch
one another, speed of writing letters spontaneously
from memory, and converting lower case letters to
upper case letters, and vice versa special features. The
THS, Cursive version (for children ages 8 years to 10
years 11 months) has in addition to the 206 scorable
letters, only one feature: speed of writing letters
spontaneously from memory.
Does it give a clinical diagnosis? No.
PURPOSE
The purpose of the THS is to measure how a child can
write letters, words, and numbers spontaneously, from
dictation, or from copying. It is also used to determine
the speed by which a child can produce letters spontaneously. These components of the assessment can
identify both the strengths and weaknesses of a childs
handwriting that can be used to develop a remedial
program. The goal of remediation is to improve a
childs legibility of letters, words, and numbers, along
with increasing speed of writing.
DERIVATION
Overall test developed based on literature review.
Words used in dictation components were determined
by a group of 15 teachers.
PUBLISHED MATERIAL
Author/Others: Author (Gardner, 1998); others
Usefulness: Quality and rate ndings of the assessment
are used to identify both the strengths and
weaknesses of a childs handwriting that can be used
to develop a remedial program.
Validated: On 839 children (Gardner, 1998) from a
nationwide sample with normative data determined
after analysis. Construct validity was in the moderate
range. Concurrent validity studies yielded positive
correlations with the TVMS-R, WRAT-3 (spelling
component), Bender, and VMI.
Reliability: Internal consistency was described as
acceptable with reliability coefcients ranging
from .51 to .78.
Additional Statistical Analysis: None
ASSESSMENT COMPONENTS
Type of Assessment: Spontaneous composition, dictation
and near-point copy assessment
Task(s): (a) Writing from memory, upper case letters of
the alphabet in sequence; (b) writing from memory,
lower case letters of the alphabet in sequence; (c)
writing from dictation, upper case letters of the
alphabet out of sequence; (d) writing from dictation,
lower case letters of the alphabet out of sequence; (e)
writing from dictation, numbers out of numerical
sequence; (f) copying selected upper case letters from
the alphabet; (g) copying selected lower case letters
from the alphabet; (h) copying selected words; (i)
copying selected sentences; and (j) writing from
dictation selected words.
Paper Type: Supplied unlined paper in test booklet
Pencil Type: Standard number 2 pencil
REFERENCES
Alston J, Taylor J (1987). Handwriting: Theory,
research, and practice. Worcester, MA, Billings.
Burnhill P, Hartley J, Lindsay D (1983). Lined paper,
legibility and creativity. In J Hartley, editor: The
psychology of written communication. London, Kogan
Page.
Gardner M (1998). The test of handwriting skills:
manual. Hydesville, CA, Psychological and Educational Publications.
314
CHILDRENS HANDWRITING
EVALUATION SCALE
AUTHOR, YEAR
PARTICIPANTS
Children: Third through eighth graders
Developmental Level: Grade level
DESCRIPTION
The Childrens Handwriting Evaluation Scale (CHES)
is used to assess cursive handwriting in third through
eighth graders who have knowledge of the English
language. The CHES assesses Rate to copy the passage
(consisting of 197 letters) and ve quality categories of
the sample: Form, Slant, Rhythm, Space, and General
Appearance. Rate and quality are evaluated independently on a ve-point scale: very poor, poor, satisfactory,
good, and very good. Percentile ranges can be assigned
to correspond with rankings. In addition, percentile,
standard scores, T-scores, and stanines are provided for
Rate of writing for each grade.
CONTENTS
What does the schedule try to measure? The CHES
assesses handwriting performance. Specically, Rate
for the whole writing sample and ve quality categories (form, slant, rhythm, space, and general
appearance) for the whole sample are measured.
Does it give a clinical diagnosis? No.
PURPOSE
The main purpose is to assess the rate and quality of a
students handwriting. It is recommended that interpretive ratings obtained after scoring the CHES be
used to guide need for further assessment and the
remediation process.
ASSESSMENT COMPONENTS
Type of Assessment: Near-point copy assessment
Task(s): The student is required to copy a passage from
a printed stimulus sheet directly below
Paper Type: Supplied unlined blank sheet with the
passage on top
Pencil Type: Number 2 pencil
DERIVATION
No information identied.
PUBLISHED MATERIAL
Author/Others: Author (Phelps & Stempel, 1984);
others
Usefulness: Interpretive ratings obtained after scoring
the CHES should be used to guide need for further
assessment and the remediation process.
Validated: On 1365 third- through eighth-grade
students in Dallas County Schools (Phelps &
Stempel, 1984) with cutoff scores determined after
analysis. Content validity was established in development (Phelps & Stempel, 1984).
Reliability: Interrater ranged from 0.88 to 0.95
(ICC).
Additional Statistical Analysis: The reasons for need
for remediation (performance below the 24th percentile) were studied with 9% needing remediation
for quality only, 13% for rate only, and 2% for both
rate and quality. In addition, rate scores for the CHES
were compared with rate scores for the American
Handwriting Scale (1957) (no longer available).
Findings showed that students in 1984 wrote at a
slower rate than in 1957 and that the AHS yielded
more letters of writing at all grade levels.
REFERENCE
ASSESSMENT COMPONENTS
CHILDRENS HANDWRITING
EVALUATION SCALE FOR
MANUSCRIPT WRITING (CHES-M)
AUTHOR, YEAR
Phelps, 1987
DESCRIPTION
The CHES-M is used to assess manuscript handwriting
in rst and second graders who have knowledge of the
English language. The CHES-M assesses Rate to copy
the sentences (consisting of 57 letters) and 10 quality
components in four main categories: Form, Rhythm,
Space and General Appearance. Rate and Quality are
evaluated independently. Percentile ranks and standard
scores are provided for Rate of writing for each grade.
With respect to quality ratings, 10 points were assigned
to each constituent. When all are present, 100 points
are possible with 10 points deducted for each criterion
not met. Scores between 10 and 40 are considered
poor; between 50 and 70, satisfactory; and between 80
and 100 good. Percentile ranks and standard scores are
provided for a quality total score based on rating.
CONTENTS
What does the schedule try to measure? The CHES-M
assesses handwriting performance. Specically, the
CHES-M measures Rate for the whole writing sample and four quality categories: Form (small letters
are uniform in height and proportion, tall letters
are higher than small and suitably proportioned
and aligned, correctly formed and recognizable out
of context, letters copied correctly); Space (space
between letters of a word uniform, space between
words adequate and uniform, right margin uncrowded,
space between lines uniform); Rhythm; and General
Appearance
Does it give a clinical diagnosis? No.
PURPOSE
The main purpose is to measure rate and quality of
manuscript handwriting. It is intended to provide a
PARTICIPANTS
Children: First and second graders
Developmental Level: Grade level
DERIVATION
Derived from the CHES with the same schools used for
norming purposes.
PUBLISHED MATERIAL
Author/Others: Author (Phelps, 1987); others
Usefulness: It is intended to provide a standard by
which to monitor gradual improvement or immediately dene specic problem areas.
Validated: On 643 rst- and second-grade students in
Dallas County Schools (Phelps & Stempel, 1984)
with cutoff scores determined after analysis. Content
validity was established in development.
Reliability: Interrater ranged from 0.85 to 0.93
(ICC).
Additional Statistical Analysis: None.
316
REFERENCE
ASSESSMENT COMPONENTS
Type of Assessment: Spontaneous composition, dictation, near-point, and far-point copy assessment
Task(s): The ETCH-C has the following tasks: (a)
writing from memory, upper and lower case letters of
the alphabet in sequence; (b) writing from memory,
the numbers 1 to 20 in sequence; (c) near-point
copying a short sentence; (d) far-point copying a
short sentence; (e) manuscript-to-cursive transition a
short sentence; (f) dictation three nonsense words;
and (g) sentence composition. The ETCH-M consists of all of the preceding subtests with the exception of manuscript-to-cursive transition.
Paper Type: Supplied lined paper in test booklet
Pencil Type: Standard number 2 pencil
EVALUATION TOOL OF
CHILDRENS HANDWRITING
AUTHOR, YEAR
Amundson, 1995
DESCRIPTION
The Evaluation Tool of Childrens Handwriting
(ETCH) is designed to evaluate manuscript (ETCHM) and cursive (ETCH-C) handwriting skills of children in grades 1 through 6 who are experiencing
difculty with written communication. The ETCH
contains seven cursive writing tasks and six manuscript
writing tasks, plus items addressing the childs ability to
handle the writing tool and paper. The primary focus of
the ETCH is to assess a childs legibility and speed of
handwriting in writing tasks that are similar to those
required of students in the classroom. The ETCH also
examines specic legibility components of a childs
handwriting such as letter formation, spacing, size, and
alignment, as well as a variety of sensorimotor skills
related to the childs handling of the writing tool and
paper. Subtest and ETCH total scores are calculated as
percentages on the basis of the number of readable
letters, words, and numbers against possible letters,
words, and numbers.
CONTENTS
What does the schedule try to measure? The ETCH
examines specic legibility components of a childs
handwriting (manuscript or cursive) such as letter
formation, spacing, size, and alignment, as well as a
variety of sensorimotor skills related to the childs
handling of the writing tool and paper. These components are measured from spontaneous composition, dictation, near-point, and far-point copying
tasks.
Does it give a clinical diagnosis? No.
PURPOSE
The primary purpose of the ETCH is to assess a childs
legibility and speed of handwriting in writing tasks
that are similar to those required of students in the
classroom.
PARTICIPANTS
Children: Children in grades 1 through 6, ages 6 years,
0 months to 12 years, 5 months
Adults: Can be used to gather descriptive information
related to their functional handwriting performance.
Developmental Level: Grade level
DERIVATION
Writing sample and scoring criteria were developed
from a pilot version through literature review and eld
testing with revision.
PUBLISHED MATERIAL
Author/Others: Author (Amundson, 1995); others
(Diekema, Deitz, & Amundson, 1998; GraceFrederick, 1998; Koziatek & Powell, 2002; Schneck,
1998; Sudsawad et al., 2001)
Usefulness: Useful in assessing a childs legibility and
speed of handwriting in writing tasks that are similar
to those required of students in the classroom. This
is useful in analyzing underlying sensorimotor
functions of handwriting and assessing handwriting
quality to determine the need for intervention and
baseline for monitoring progress.
Validated: Although one construct validity study
(Grace-Frederick, 1998) showed agreement between
teacher ratings of poor handwriting and poor per-
REFERENCES
Amundson SJ (1995). The evaluation tool of childrens
handwriting (ETCH). Homer, AK, OT Kids.
Diekema SM, Deitz J, Amundson SJ (1998). Testretest reliability of the Evaluation Tool of Childrens
Handwriting, Manuscript. American Journal of
Occupational Therapy, 52:248254
Grace-Frederick L. (1998). Printing, legibility, pencil
grasp, and the use of the ETCH-M. Boston, Boston
University, Unpublished masters thesis.
Koziatek SM, Powell NJ (2002). A validity study of the
Evaluation Tool of Childrens Handwriting-Cursive.
American Journal of Occupational Therapy,
56:446453.
Ottenbacher KJ, Tomchek SD (1994). Measurement
error in method comparison studies: An empirical
examination. Archives of Physical Medicine &
Rehabilitation, 75(5):505512.
Schneck CM (1998). Clinical interpretation of TestRetest Reliability of the Evaluation Tool of Childrens Handwriting-Manuscript. American Journal
of Occupational Therapy, 52:256258.
DESCRIPTION
The Handwriting Speed Test (HST) is a standardized,
norm-referenced test of handwriting speed for children
and adolescents in grades 3 through 12. It is intended
to be used as one component of a multifaceted assessment of handwriting. After a 3-minute trial of copying
the words the quick brown fox jumps over the lazy
dog as many times as they can, a letters per minute is
obtained and converted to a scaled score. The scaled
score can be used in determining the eligibility of students for extra time or other assistance in examinations,
identifying children who require intervention for
handwriting speed difculty, and evaluating the effects
of intervention on handwriting.
CONTENTS
What does the schedule try to measure? Handwriting speed
for children and adolescents in grades 3 through 12.
Does it give a clinical diagnosis? No.
PURPOSE
The HST was developed to provide an up-to-date and
objective means of evaluating the handwriting speed of
students presenting with handwriting difculties.
ASSESSMENT COMPONENTS
Type of Assessment: Near-point copy assessment
Task(s): The student is asked to copy from a typed
Handwriting Sample Form onto lines below the
words the quick brown fox jumps over the lazy
dog as many times as they can in a 3-minute period.
Paper Type: Supplied lined paper with center dotted line
Pencil Type: Number 2
318
PARTICIPANTS
Children: Third through twelfth graders
Adults: Young adult (high school aged)
Developmental Level: Can be used for children with
physical disabilities, learning disabilities, or specic
handwriting difculties
DERIVATION
PUBLISHED MATERIAL
REFERENCES
Wallen M, Bonney M, Lennox L (1996a). The
handwriting speed test. Adelaide, Australia, Helios.
Wallen M, Bonney M, Lennox L (1996b). Interrater
reliability of the Handwriting Speed Test. Occupational Therapy Journal of Research, 16:280287.
Wallen M, Mackay S (1999). Test-retest, interrater, and
intrarater reliability and construct validity of the
Handwriting Speed Test in year 3 and year 6 students. Physical and Occupational Therapy in Pediatrics,
19:2942.
Chapter
15
CHAPTER OUTLINE
DEVELOPMENTAL EXPERIENCES THAT UNDERLIE
SKILLED USE OF THE HANDS
Upper Extremity Support
Wrist and Hand Development
Visual Control
Bilateral Integration
Spatial Analysis
Kinesthesia
Summary
HANDWRITING TRAINING: PENCIL GRIP
Tripod Grip and Alternative Grips
Remediation of Pencil Grip
KINESTHETIC APPROACH TO TEACHING
HANDWRITING
Cursive or Manuscript Writing
Motor Patterns in Cursive Writing
Why Teach Writing Kinesthetically?
Kinesthetic Teaching Method
Kinesthetic Remediation Techniques
SUMMARY
319
320
DEVELOPMENTAL EXPERIENCES
THAT UNDERLIE SKILLED USE OF
THE HANDS
Since 1992 as fear about sudden infant death syndrome
(SIDS) became widespread, the Back to Sleep
Campaign was implemented to lower the risk of SIDS
(SIDS Task Force). Many anxious parents misinterpreted this warning to mean their baby should never be
prone, even during daytime play periods.
While supine or semireclined in a variety of plastic
exoskeletons infant seats, the baby can barely raise
his or her head, much less bear weight on the upper
extremities and elongate and strengthen the cervical
spine. Tummy Time in prone posture facilitates head
lifting and neck strengthening, trunk stability, and
balance while weight bearing on the upper extremities.
Therefore lack of prone positioning during the babys
play periods lengthens the time it takes to master such
basic skills as lifting and holding the head, pivoting,
turning over, and sitting and crawling. Lack of weight
bearing on the hands may affect hand structures; underdeveloped arch formation and stabilization, incomplete
expansion of the thumb-index web space for full
opposition, and skilled manipulation of tools. Skilled
use of tools (e.g., silverware, scissors, pencils) often lags
because of lack of full range of motion at the carpometacarpal (CMC) joint of the thumb.
To be effective in promoting efcient graphic skills,
developmental therapists must address these unresolved
ergonomic factors (i.e., postural, tonal, stabilizing) in
addition to ne motor intervention. Graphomotor production difculties usually cluster under one or more of
the following classications: (a) incomplete range of
motion and use of the proximal joints of the upper
extremity, (b) immature wrist and hand development
with clumsy distal manipulation skills, (c) insufcient
experience in eye-hand control, (d) incomplete bilateral
integration, (e) inadequate spatial analysis or synthesis
skills, and (f) reduced somatosensory input with failure
to develop kinesthesia.
BOX 15-1
322
Figure 15-2
Benbow.)
wrist and thumb postures, and visual and hand dexterity for their expressive needs. Today skilled artists rarely
draw or paint on a horizontal surface.
324
VISUAL CONTROL
Numbers 1-10
Top to bottom
Name:
326
BILATERAL I NTEGRATION
Bilateral integration and sequencing (BIS) dysfunction
is a common cause of motor delays or decits (Ayres,
1991). In addition to well-documented gross motor
decits (e.g., postural, equilibrium, and body side coordination), a child with BIS dysfunction is slow to
establish a good division of labor between the two
hands. By the time most peers are performing well in
the graphic motor area, the child is still using the hands
interchangeably to do far less sophisticated activities.
On paper and pencil tasks the child usually experiences
an interruption in crossing the visual midline and produces reversals long after other classmates have resolved
this issue. The child is unable to change stroke direction in a continuous flow pattern. This is evidenced as
an inability to shift the right under-curving lead-in
for
Figure 15-8
for
for
SPATIAL ANALYSIS
Children with nonlanguage learning disabilities
(NLD), which include difculties with math, nonphonetic spelling, and visualizing, usually lack strategies
to analyze geometric shapes, numbers, and letters.
These children require detailed letter analysis help to
learn to write. Small incremental steps (including starting place, pencil progression, distance and speed at
which to move the pencil, and stopping point) must be
examined and explained and re-examined and reexplained. Retraces, the point of intersection with leadin strokes, and instructions for the release stroke or
328
KINESTHESIA
Writing is a motor skill and, as with other motor skills,
efcient writing depends on kinesthetic input. Motor
skills developed kinesthetically, such as riding a bike,
keyboarding, or handwriting, are most permanent. In
writing, an internal sensitivity that a letter movement
feels correct reduces a childs need to visually monitor
the ngers or pencil point while moving along the line.
This security enhances speed in learning and condence
in cursive writing. Kinesthetic writing naturally accelerates over time to functional speed without the reduction of performance quality seen with visually guided
writing. The visual system is far too slow and mechanical to monitor the serial chain of nger movements
necessary for note taking much beyond mid third
grade. Advising a child to slow down (allowing time to
visually monitor the writing hand) temporarily results
BOX 15-2
2nd
3rd
1st
Home
Plate
Figure 15-13
Benbow.)
330
SUMMARY
Children who benet from ongoing diagnostic handwriting training usually have identiable problems in
one or more foundation skills. The rst is gross and
ne motor readiness for cursive instruction. Output or
production problems can include difculties with rapid
sequential movements (often noted in the childs early
history as articulation problems), visual control,
bilateral integration, and spatial analysis and synthesis.
Feedback difculties include inadequacies in visual and
kinesthetic reafferent systems.
Developmentally sequenced hand activities should
be a major ne motor focus in preschools and early
elementary education. Early educators should develop
the full potential of childrens hands for all skills
because the remediation of prewriting hand skills
greatly facilitates the learning of graphic skills. The
following sections turn to two specic aspects of handwriting training, pencil grip and kinesthetic writing.
HANDWRITING TRAINING:
PENCIL GRIP
Letter production skill can be influenced by the way
the writer grips a writing tool. This section includes a
Figure 15-15
Benbow.)
332
BOX 15-3
334
Figure 15-21 Neoprene thumb abduction splints. (Available from Benik Corp., www.benik.com; McKie,
www.mckiesplints.com; copyright Mary Benbow.)
BOX 15-4
1. The instructor demonstrates placement of the pencil positioned between the index and long ngers to
make large random patterns using only shoulder
and elbow movements.
2. The child imitates the pencil position and makes
large free flowing movements following this rigid
rule: No nger movements!! No letters!! No
numbers!!
3. After the child accommodates to the feel of the
pencil in the index/middle nger web space, the
child should draw anything he or she pleases.
4. Once the child is at ease with the new pencil position, he or she should be encouraged to write large
isolated numbers and letters.
5. When the new grip becomes annoying, the child
should temporarily shift back to the former grip.
6. As soon as he or she feels ready, the child should
return to the adapted grip.
7. When a child is in control of the alternating time
shifting scheme, and experiences comfort and
success, he or she tends to use the adapted grip
more consistently.
KINESTHETIC APPROACH TO
TEACHING HANDWRITING
C URSIVE OR MANUSCRIPT WRITING
One of the difculties facing anyone investigating
handwriting teaching and remediation issues is the lack
of longitudinal studies in the eld. Studies of preparatory skills, curriculum techniques, and timetables for
the consolidation of writing skill at an automatic level
are scarce. Tradition rather than scientic investigation
has guided the teaching of handwriting in America. For
example, there are no studies to substantiate the practice of using manuscript throughout kindergarten and
rst and second grade. In fact there is considerable
evidence showing that such teaching may impede the
development of functional handwriting in some students. Cursive instruction typically is introduced at the
beginning of grade 3 in most American school systems.
Several motor patterns adopted for printing and
reinforced by 3 to 5 years of use are often resistant to
change at age 8. In manuscript, children become accustomed to having the paper square to the edge of the
desk in order to write. Later, slanting the paper to
the appropriate angle to accommodate the wrist for
diagonal down and up stroking in cursive is motorically
336
disconcerting for many children. The DNealian manuscript program is unique in that letters are practiced
with the paper positioned at an angle to take advantage
of the wrist flexors in down stroking. Interestingly, this
angling of the paper is benecial only when the radial
side of the hand is used to guide the pencil to write.
However, this placement of the paper is usually
demanded of all children regardless of grip. In addition, the eye-hand pattern of top to bottom control of
vertical strokes needs to be shifted to bottom to top
under curving diagonals.
The strategy for gaining an understanding of ball
and stick manuscript letters requires whole-to-part
analysis followed by synthesis of the parts back into
wholes. For many children it is perplexing to alter the
process and analyze and integrate movement for the
whole letter formation necessary for cursive writing.
Again the DNealian manuscript program has been the
most successful in reducing segmentation of lines for
letter formations.
In more than 30 years of experience in the teaching
of handwriting, this author has found that second
grade is an optimal time for most children to learn
cursive handwriting. Student interest is high, and generally students have not yet developed faulty habits
of inventive cursive before formal instruction begins.
Training activities of combining letters into simple twoand three-letter words to practice letter formations and
connector units are at a more appropriate cognitive
level for second-grade students. Initiating cursive writing instruction in the fall of second grade allows a full
year for students to stabilize this motor learning before
the higher volume of written work is demanded at the
third-grade level.
Curricula that use instructional techniques to accommodate for perceptual and motor delays and decits
should enable nearly all children to advance to cursive
writing at an earlier age. In schools in which cursive
writing is introduced earlier and mastered kinesthetically, there is less confusion with and substitution of
manuscript letters with cursive letters. Programming
ample time to master cursive writing reduces the number of children who revert to manuscript in middle
school when the output volume increases dramatically.
The most perplexing problem for parents, teachers,
and students themselves is how the student can have
excellent ne motor skills and horrible handwriting.
Levine (2003) explains that ne motor skills mainly
recruit the ngers to manage artwork, origami, or
airplane models, which are all navigated by the eyes.
Graphomotor functions take place over different neural
pathways and require rapid sequential movements
guided by ongoing sensory feedback from the digits.
The eyes are far too slow to monitor the movement of
the digits as they move at a functional speed. Levines
338
Clock Climbers
Kite Strings
Loop Group
Figure 15-23 Practice sheet for distal finger control. (From Loops and other groups: A kinesthetic writing system. Copyright
1990 by Harcourt Assessment, Inc. Reproduced with permission. All rights reserved.)
Figure 15-24
Presentation of a Model
The instructor introduces the letter by producing
about a 15-inch model of it within the appropriate line
space(s) on the chalkboard. While demonstrating each
new letter, the instructor should recite each step of the
motor plan. Familiar objects in the students environment are used to aid the students in visualizing the
movement pattern as they motorically produce the
340
Preparatory Exercises
Before using pencils and paper, children perform two
exercises. In each exercise they are to use the hand
posture shown in Figure 15-27. Digits II and III are
extended. Digits IV and V are flexed and held down
with the thumb to reinforce separation of the two sides
of the hand. For each exercise and each practice trial,
verbal directions should be voiced by the teacher and
the students.
The students should use the shoulder movements
and hand postures described previously to trace the
letter in the air. Simultaneously each student verbalizes
the motor plan while following the shape of the chalkboard model. Each student in the class must demonstrate the ability to verbalize the motor plan while
following the line of the letter model.
When secure in an understanding of the motor
sequence, each student closes the eyes and pictures the
letter to facilitate visualization of the movement pattern. During the second exercise, students place their
elbows on the desk top to write using elbow and wrist
movements. Again, they must recite the motor plan as
they move their hands to pattern the visualized letter.
These preparatory exercises are important to the
initial learning of handwriting. The instructor is able to
determine which children are unable to visualize the
letter with eyes closed or averted from the model letter
SUMMARY
Kinesthetic handwriting training takes the drudgery
out of a task that is often difcult and time-consuming.
For all children and for their teachers, this provides
some benet. For some children, kinesthetic training is
the single most effective tool for learning handwriting.
Children who benet the most from kinesthetic
handwriting training usually have identiable problems
in one or more general areas. Developmental gross and
ne motor foundation skills for cursive instruction may
be less than optimal. Output or production problems
may include difculties with visual motor control.
Kinesthesia is the key to the lost science of handwriting. Properly understood, it is the basis for understanding handwriting problems and for preventing or
remediating them. Kinesthesia can be a curse or a
blessing. When a complex motor activity is scientically
analyzed, appropriate foundation skills are set, teaching
steps are properly sequenced, and the skill is practiced
to the automatic level of performance, kinesthesia is a
lifelong blessing in the performance of that skill. On
the other hand, maladaptive kinesthetic patterns can be
Figure 15-26 Practice sheet for clock climber group (a, d, g, q, c). (From Loops and other groups: A kinesthetic writing
system. Copyright 1990 by Harcourt Assessment, Inc. Reproduced with permission. All rights reserved.)
342
REFERENCES
American Academy of Pediatrics Task Force on Infant Sleep
Position and SIDS (2000). Changing concepts of sudden
infant death syndrome: Implications for infant sleeping
environment and sleep position. Pediatrics, 105:650656.
Ayres AJ (1991). Sensory integration and praxis tests. In
AG Fisher, EA Murray, AC Bundy, editors: Sensory
integration, theory and practice. Philadelphia, FA Davis.
Beery KE (1997). Developmental test of visual motor
integration, VMI-4. Los Angeles, Psychological
Corporation.
Benbow M (1990). Loops and other groups: A kinesthetic
writing system. Tucson, AZ, Therapy Skill Builders, a
division of Communication Skill Builders, Inc.
Benbow M, Hanft B, Marsh D (1992). Handwriting in the
classroom: Improving written communication. The
American Occupational Therapy Association Self Study
Series. Rockville, MD, The American Occupational
Therapy Association Press.
Bernier R (1991). Matisse, Picasso, Miro: As I knew them.
New York, Alfred A. Knopf.
Berninger V, Rutberg J (1992). Relationship of nger speed
to beginning writing. Developmental Medicine and Child
Neurology, 34:198215.
Chapter
16
CHAPTER OUTLINE
CEREBRAL PALSY
TREATMENT PLANNING
SUMMARY
343
344
CEREBRAL PALSY
Cerebral palsy is a general term that describes a nonprogressive group of posture and movement disorders
diagnosed within the rst 2 to 3 years of life (Koman,
Smith, & Shilt, 2004). The apparent causes of CP
come from a variety of sources, including maternal
infection, prematurity, multiple births, hypoxia associated with birth trauma, and maternal bleeding from
premature placental separation, to mention a few
(Nelson & Grether, 1999). Although the insult to the
CNS is believed to be static, impairments seen with CP
include musculoskeletal concerns, muscle weakness,
spasticity, vision problems, cognitive limitations, and
seizures. Secondary conditions related to the various
primary impairments continue to evolve across the life
span and include muscle tightness and contracture,
joint abnormalities such as dysplasia and dislocation,
growth problems, pain, social isolation, and diminished
ability to participate in the community through occupations such as education, work, and leisure. Evidence
suggests that loss of function seen in typical aging is
accelerated in CP, and that the secondary conditions
associated with CP become more common and more
severe with age (Andersson & Mattsson, 2001; Cathels
& Reddihough, 1993; Murphy, Molnar, & Lankasky,
2000; Turk et al., 1997).
The incidence of CP over the last 20 years, currently
estimated at 2 to 4 per 1000 children, appears to be
increasing. This change may result from many factors,
including improved documentation of the diagnosis in
countries around the world, improved care of premature and sick infants, or other unknown factors (Nelson
& Grether, 1999).
The movement disorders associated with CP include
spasticity, dyskinesia or dystonia, hypotonia, and ataxia.
Spasticity is the most frequently occurring disorder and
a mixture of various movement disorders are common.
The accepted distributions of movement impairment
include hemiplegia, diplegia, and quadriplegia (Dabney,
Lipton, & Miller, 1997).
Although improved care has resulted in typical life
spans for persons with less signicant involvement,
those with severe quadriplegia and associated conditions may die earlier (Hutton & Pharoah, 2002;
Strauss & Shavelle, 1998). Strauss, Cable, and Shavelle
(1999) carried out an epidemiologic review of a large
database targeting causes of death in CP. Their ndings found elevated death rates from cancer and heart
disease occurring at relatively young ages. Although
this study awaits replication and support from clinical studies, the ndings are provocative to say the
least.
THE NEURODEVELOPMENTAL
TREATMENT APPROACH AND
PEDIATRIC THERAPY
The intervention approach discussed in this chapter is
the neurodevelopmental treatment approach, or NDT,
originally called the Bobath approach. This paradigm
hypothesizes that abnormal tone and impairments of
movement and posture result from lesions in the CNS
and limit the development of function. Intervention is
aimed at minimizing these impairments and improving
functional outcomes as a result of problem-solving
among the clinician, client, and family to develop new
movement strategies and management of postural tone.
The original approach was developed by Berta and
Karel Bobath, a physiotherapist and physician, respectively, who evolved the paradigm between late 1940
and 1990. Currently the instructors who teach the
technique and the national Neurodevelopmental Treatment Association (NDTA) continue to expand and
update the treatment approach.
When Mrs. Bobath rst began to practice as a physical therapist, therapeutic interventions for neuromuscular diagnoses were based on the stretching and
strengthening regimens used with the impairments left
after polio. Unhappy with the results of such treatments, Mrs. Bobath documented observations from
her assessment and treatment of adults with paralysis
after stroke and children with CP. Dr. Bobath supported her ideas with information from the neurophysiologic scientists of the day, including the hierarchic
perspective of the CNS, the cephalad to caudal/proximal
to distal nature of human development, and the concept that postural control evolved from primitive reflexes
(Howle, 2004). The Bobaths early work focused on
altering muscle tone and reflexes to enable the development of more normal movements and followed the
normal developmental sequence in treatment. The
importance of the postural reflex mechanism was highlighted and primitive reflexes were seen as a rst step in
the development of higher-level, skilled movements.
The persistence of these reflexes in conditions such as
CP originally was believed to block more skilled movement, hence the concept of reflex-inhibiting postures
(RIPs), which were used to facilitate higher level
movements (Bobath, 1955).
Over time, Mrs. Bobaths approach changed as she
documented her observations about the results of her
treatment. Although the concept of reflex inhibition,
even today, is seen by some as the substance of NDT,
Mrs. Bobath actually discarded this focus by 1964,
moving on to the idea of handling or moving the
ROLE OF PERFORMANCE
COMPONENTS ON
OCCUPATIONAL PERFORMANCE
Aspects of performance that therapists analyze when
planning treatment for children with CP are components such as postural control, strength, muscle tone,
spasticity, range of motion, and the performance of the
activity or occupation designated as the goal of intervention. Current studies provide a much clearer picture
of the role such impairments and movement disorders
have on performance skills. For example, Gordon and
Duff (1999b) studied the relationship between ngertip force regulation in grasp, spasticity, stereognosis,
two-point discrimination, manual dexterity, and perception of pressure sensitivity. Their work demonstrated
a clear relationship among tactile perception, anticipatory control (activation of sensory and muscular systems for a specied activity based on prior learning and
experience) (Shumway-Cook & Woollacutt, 2001) and
task performance; however, it also suggested that the
role of the other impairments in performance was
dependent on the aspects of the activity being performed.
They noted that spasticity appeared to affect the adjustment of grip to object weight and to the length of time
between grasping and actually lifting an object, but it
did not have a relationship to anticipatory control.
The NDT approach emphasizes the importance
of postural control and anticipatory postural control,
both performance skills in the Occupational Therapy
Practice Framework (The American Occupational
Therapy Association [AOTA], 2002), to the outcomes
of therapy intervention, or areas of occupation. The
next section of this chapter discusses postural control
and its impact on upper limb function.
346
KINESIOLOGIC ASPECTS OF
TRUNK AND ARM FUNCTION
The problems with postural control and upper limb
function seen in children with CP affect all aspects of
occupational performance. It is for this reason that
evaluation of posture, postural adjustments, and their
interactions with the upper limb particularly should be
part of a therapeutic assessment, as well as the status of
body structures.
348
Arranging hair on the back of the head, clipping toenails, bathing, and dressing are all examples of activities
that require the hand to be moved to a distance away
from the body. In typical movements, certain shoulder
complex functions are aided by actions of the spine. For
instance, rotation and flexion of the lumbar, thoracic,
and cervical spine extends the range of reach for items
high on a shelf or under a bed.
The rotary movements of the shoulder and forearm
are particularly important to skilled dexterous movements within and between the hands, both at and away
from midline. Removing post earrings, for example,
requires the palms of the hands to be facing each other
on one side of the body, an action that would not
be easily performed without humeral and forearm
rotation.
Finally, the complexity of wrist and hand movements
is signicant and remarkable for the highly complementary nature of the interactions among various structures. Consider playing the piano and the conguration
of the wrist and ngers. During an octave stretch, the
wrist may be flexed to provide additional range of
movement in abduction and extension at the ngers.
When a chord is played, the wrist is extended to
provide power, stability, and control for the flexed
ngers. Knowledge of these kinds of interactions assists
the therapist to both understand and treat limitations
in occupational performance that involve the hands.
Awareness of the complex structures in the hand is
critical as well, including the carpal, metacarpal, phalangeal joints, and arches.
BIOMECHANICAL INTERACTIONS
OF THE UPPER LIMB IN
CEREBRAL PALSY
Depending on muscle tone and distribution of motor
impairment in the individual with CP, there are
commonly fluctuations in movement control that affect
position of the spine and pelvis and postural adjustment
responses (Liao et al., 2003; Van der Heide et al.,
2004). These difculties can be increased by tightness
in the soft tissue structures of the lower limbs, such as
the hamstrings and hip flexors (Reid, 1996). Such
problems in the axial structures influence purposeful
movements in the upper limbs of children with CP.
Posterior tilt of the pelvis and flexion of the lumbar
spine increase thoracic flexion and compromise actions
in the shoulder girdle and shoulder.
As discussed, changes in any aspect of shoulder
girdle function influence the entire shoulder girdle
complex (Neumann, 2002). Scapulohumeral rhythm is
commonly affected by increased thoracic flexion,
causing the scapula to rotate upward sooner in the
interaction of the two structures and sometimes limiting the range of overhead action. Movements in the
frontal plane, such as humeral flexion and horizontal
adduction, seem to be difcult for children with CP,
resulting in the increased presence of humeral abduction and sometimes humeral extension. External rotation of the humerus is affected by both increased
thoracic flexion and the resulting scapular abduction,
which biomechanically aligns the humerus into an
internally rotated posture. This conguration is most
often seen in children with spasticity; those who have
dyskinesia or dystonia may seek to control extraneous
movement in their upper limbs by holding their upper
limbs against their bodies in a practice called xing or
stabilizing the upper limb (Nichols, 2001). This practice volitionally can limit their humeral motions
initially; however, if the practice persists, actual soft
tissue limitations can occur.
TREATMENT APPROACHES:
CONCEPTS OF INHIBITION
AND FACILITATION
Three concepts underscore therapeutic handling (facilitating active movement by using a hands-on approach)
in the NDT treatment approach, key points of control,
inhibition, and facilitation. Key points of control refers
to specic hand placement by the therapist during
handling that allows direct influence or control over
the area and indirect control over other body structures
or functions proximal or distal to the key point. These
sources of control are used to either inhibit or facilitate
movement sequences and postural control. Proximal
key points include the pelvis, shoulder girdle, and trunk,
whereas distal key points are areas such as the elbow
and ankle. Inhibition is dened as
the reduction of specic underlying impairments that interfere
with function (Howle, 2004, p. 261).
350
I NHIBITORY TECHNIQUES
Inhibition is the primary tool used to manage abnormal
posture and tone. Specic hands-on inhibitory techniques such as vibration, use of mobile surfaces,
location, position of structures within the treatment
environment, and use of various sensory stimuli and
speed of movement can all be used to minimize
impairments.
Vibration in NDT consists of placing the hand on a
body area and vibrating or oscillating the location
gently and consistently. Use of mechanical vibrators is
discouraged because of the noise and difculty grading
the intensity of the vibration. This technique is best
used when a more global movement or gross motor
activity is being performed so as not to interfere with
performance. It is particularly useful when managing
trunk tone for vocalization or extending the range of
movement in the trunk or a limb. As with all inhibitory
techniques, one should withdraw the technique during
activity performance.
Prolonged stretch through weight bearing in both
upper and lower limbs is an inhibitory technique used
to elongate soft tissue structures and minimize flexion
BOX 16-1
INHIBITORY TECHNIQUES
Vibration
Prolonged stretch
Therapist guidance of movement
Use of mobile surfaces
Inhibition through activity
FACILITATION TECHNIQUES
Deep pressure and joint approximation
Weight bearing on both upper and lower limbs
Vestibular input
Environmental modications
Sensory modications
Combining inhibition and facilitation
FACILITATION TECHNIQUES
The use of key points of control combined with therapist
guided movement plays a big role in facilitation.
Remember that key points of control are body areas
from which the therapist facilitates or inhibits movement. In facilitation, the goal might be to assist the
client to open a cupboard door using a more involved
upper limb while the unimpaired limb holds and then
places an item into the cupboard. The therapist could
use either the shoulder or elbow as a key point of
control to facilitate placement of the impaired arm
on the door handle, a task that the client cannot do
without prompts.
352
approach, remember that the approach addresses posture and movement in the context of occupational
performance. This means that occupational performance needs to be assessed. Pediatric therapists have a
host of tools available to them in this realm, some of
which have a developmental or skill focus. The reader
should see Asher (1996) for a complete listing.
TREATMENT PLANNING
Planning appropriate interventions and documenting
outcomes are aspects of service provision that require
careful attention. Setting appropriate goals is the
cornerstone of treatment planning. As noted in the OT
Practice Framework, the occupations selected as outcomes of intervention should be meaningful and
purposeful to the client and family; and successful
outcomes are more likely when occupations are incorporated into daily routines (AOTA, 2002). These
premises hold true for NDT intervention just as they
do for other treatment approaches.
Use of activity analysis and the principle of partial
participation are useful tools to help build specic skills
over time (Vogtle & Snell, 2004). Refer to Table 16-1
in Case Study 1 for one example of activity analysis that
is useful when planning NDT intervention. Sensory
and motor elements are delineated to assist the clinician
in organizing treatment and incorporating strengths of
the client. Partial participation, which enables clients to
complete steps of an activity that they are able to do
with the remaining steps completed by a caregiver, can
be planned satisfactorily through the use of this kind
of activity analysis (Vogtle & Snell, 2004). Breaking
an activity into steps also helps the clinician evaluate
treatment outcomes in a more systematic manner.
Another aspect of treatment planning that benets
from activity analysis and partial participation is the
integration of accommodations into interventions. By
breaking an activity into steps and sorting out which
of those the client can do, modications to promote
successful performance can be easily identied and used
in treatment. This has the extra benet of giving the
clinician the opportunity to see if suggested modications really work before asking families and educators
to make them.
Tables 16-2 and 16-4 in the Case Studies later in the
chapter give illustrations of how a clinician could use an
activity analysis to plan treatment. The tables include
columns for activity steps, movement components, and
facilitation techniques. Organizing treatment into this
kind of table can help the clinician develop a plan for
intervention that includes aspects of facilitation and
inhibition.
354
this situation include pushing keys on a piano, computer, or toy, pressing stickers onto a surface, making
ngerprints in play dough, extending the digit for
placement, removal of a ring, and so forth. Those
activities that entail pressure (e.g., play dough, pressing
keys, stickers) are situations in which weight shifts
across the pad of the digit provide alternating deep
pressure inputs into the interphalangeal (IP) joints, as
well as the MCP joint, a facilitatory technique.
The mobility of the carpals and metacarpals of the
hand contribute to the arch structures of the hand,
wrist flexion and extension, and radial to ulnar side
interactions within the hand. All of these elements also
play a role in grasp and manipulation between and
within the hands. Hypertonic CP commonly results in
a predominance of wrist and nger flexion combined
with ulnar deviation at the wristresulting in ulnar
prehensions. Maintaining mobility in the structures
of the hand mentioned earlier while facilitating active
movement and the ability to participate in chosen
occupations are focal concerns of NDT treatment.
Although the prevailing muscle tone in the hand is
increased with generalized hypertonia, hypermobility
in the IP joints of the ngers and thumbs is common,
as well as in the MCP and carpometacarpal joint of the
thumb. This combination of increased mobility and
fluctuating tone in the spastic hand presents challenges
for the therapist and the need to alternate strategies of
inhibition and facilitation frequently when working
within the hand.
Activity demands should be considered as part
of treatment as well. AOTA (2002) denes these
demands as
. . . objects, space, social demands, sequencing or timing,
required actions, and required underlying body functions and
body structure needed to carry out the activity. (p. 624).
E FFICACY OF N EURODEVELOPMENTAL
TREATMENT
Judgment about the efcacy of therapeutic interventions should be based on careful examination of
published studies, either through systematic review or
meta-analysis. Such methods are limited by the limited
availability of high-quality studies. Two recent systematic reviews of NDT intervention have been carried
out (Brown & Burns, 2001; Butler & Darrah, 2001).
Butler and Darrah (2001) incorporated articles back
to 1973, whereas Brown and Burns (2001) included
those published since 1975. There were 21 studies in
the review by Butler and Darrah (2001) and 17 articles
in the review by Brown and Burns (2001). Both
reviews classied articles as one of ve levels of evidence. Brown and Burns (2001) used the Quality
Assessment of Randomized Clinical Trials scale created
by Jaded and co-workers (1996) to assign levels of
evidence, whereas Butler and Darrah (2001) used a
system developed by the American Academy of Cerebral
Palsy and Developmental Medicine (Butler & Darrah,
2001). Another unique feature of their review is their
incorporation of dimensions of disability reflective
of the National Center for Medical Rehabilitation
Research (NCMRR) model of disablement (ShumwayCook & Woollacutt, 2001) as one judgment of
outcome.
Both reviews cited numerous problems in attempting systematic study of NDT. Problems included
heterogeneity of the target population, lack of randomization, inadequate blinding of subjects, a wide range
of subject ages, use of a variety of clinical and standardized outcome measures, small sample size and
limited follow-up, interventions that included other
methods besides NDT, a range of duration and intensity of treatments, and inconsistency of signicance
across studies. Both studies concluded that the efcacy
of NDT could not be decided on the basis of the
studies reviewed, although Butler and Darrah noted
that studies published in the last 14 years had more
statistically signicant results. In addition, both noted
that newer interventions based on more current
theories of motor learning and skill development exist
and appear to be generating more conclusive evidence
(Butler & Darrah, 2001). Butler and Darrah cited the
lack of association to any of the NCMRR dimensions
to which the various studies were compared. These
SUMMARY
This chapter has described the neurodevelopmental
treatment approach to pediatric intervention, and its
history, evolution, and current perspective. As reiterated throughout the chapter, NDT is an intervention
focused on improving postural control and active
movement skills. The therapist bears the responsibility
for integrating this kind of approach into function and
practice of function. Carryover of movement changes
into function does not occur naturally, as once proposed by the Bobaths. Although the efcacy of NDT
has yet to be demonstrated convincingly, more recent
studies are supportive and suggest that the shift to
integration of NDT with functional outcomes has
merit in the treatment of upper limb function in children with CP.
CASE STUDY 1
A C HILD WITH C EREBRAL PALSY
Seven-year-old Jodie, who had spastic CP of quadriplegic
distribution, used a head-activated switch to work on the
computer, which meant scanning the keyboard rather than
being able to use direct selection of desired keys. Her
school therapists, teachers, and family wanted to explore
the possibility of hand activation of Jodies computer
access switch with the eventual goal of direct selection on
an alternative keyboard, which would be faster and more
productive. Although computer use in the context of the
school environment was the initial occupational goal,
success meant she would be able to access her home
computer with less assistance than she presently required.
TASK ASSESSMENT AND GOALS
Activity analysis of the process of pushing a switch (Table
16-1) and physical assessment of Jodies ability to push a
switch with her hand were carried out, along with an
assessment of performance components, activity demands,
and client factors in the OT Practice Framework (AOTA,
2002) and of performance components in Uniform
Terminology III (AOTA, 1994). Jodie demonstrated challenges in motor and process aspects of performance skills.
She maintained her head in an upright position for long
periods of time and used it to move her eyes when tracking
items. Efforts at arm and hand movement affected movements of her head and trunk, resulting in dynamic tone
changes throughout her body manifested by increased
356
Table 16-1
Step of
Activity
Visual
Component
Moves arm to
switch
Auditory
Component
Movement
Components*
Tactile
Component
Locates switch
Kinesthetic
feedback from
the limb
moving
Places hand on
switch
Humeral extension
activated to bring
hand to switch
Presses switch to
activate
Sees scanning
array activate
when switch is
pressed
Hears click as
switch is activated
Humeral extension is
used to push the
switch
Releases pressure
on the switch
Uses vision to
guide her hand
lifting to release
switch pressure
Hears click as
pressure is
released and
switch deactivated
Humeral flexion is
used to lift her hand
off the switch
Feels absence
of sensation as
her hand clears
the switch
Feels table
surface under
her hand and
arm when she
rests them on
the table
*Because the client has stiffly extended elbows, which become stiffer with efforts at movement, the choice made is to focus on
humeral movements to move her hand. Use of wrist flexion and extension also would be helpful; however, these movements are
not absolutely necessary to activate the switch.
Table 16-2
Step of Activity
Movement Component
Facilitation/Inhibition Techniques
Moves arm to
switch
Places hand on
switch
Presses switch to
activate
Releases pressure on
the switch
HANDS-ON TREATMENT
The therapist used four premises upon which to base her
treatment. First, tone increases seen in Jodie when she
attempts to use her upper limbs will be altered through
the use of work on a mobile surface (the bolster), facilitation of forward and lateral weight shifts when reaching
for her switch, and use of periodic rapid oscillations to the
upper limbs. Second, use of facilitatory tapping and activeassisted hand placement on the switch will be used to help
Jodie activate shoulder movements for hand placement,
switch depression, and switch release (see Table 16-2).
Third, practice of the task will be used to ensure changes
in motor performance, motor learning of the skill being
developed, and switch activation for computer use. Fourth,
tactile enhancement and reinforcement will be used to
ensure that Jodie knows when her hand is and is not on
the switch to help build anticipatory control mechanisms
needed for successful task accomplishment.
358
BOX 16-2
TREATMENT IMPLEMENTATION
In this section, sequencing within therapy sessions is
described, incorporating the physical environment, therapy equipment, therapeutic facilitation, and practice
components.
Tone Management and Preparation for Activity
Jodie was removed from her wheelchair for the rst 15 to
20 minutes of each 40-minute session. This enabled the
therapist to use weight shifts and techniques to modify the
dynamic muscle tone Jodie demonstrated whenever she
tried to use her upper limbs and gave her practice in use
of appropriate postural components. A bolster was used
because it enabled the therapist to use two planes of
motion: anterior/posterior movements and lateral movements. Jodie was placed on the bolster, either on the far
end or straddling it, to enable the therapist to use the
movement of the bolster when addressing Jodies muscle
tone during activities and to facilitate her active weight
shifts while providing a wide base of support. These bolster motions were activated by the therapists use of her
own lateral weight shifts and anterior or posterior body
movements.
At the same time, rapid oscillations of Jodies upper
limbs were used to help loosen her stiff arms in preparation for developing the active shoulder movements needed
to activate the switch (Figure 16-1). At this point, the
therapist had Jodie lean onto her upper limbs positioned
on the bolster to help inhibit tone and increase range in
her hands as preparation for switch activation.
Forward weight shifts accompanied the upper extremity weight bearing, passively accomplished at rst by the
therapist leaning forward into Jodies torso and moving
her forward. The therapist facilitated the weight shift in
this manner for the rst few times, and then used decreasing assistance as Jodie exhibited the ability to activate a
weight shift on her own.
Switch Activation
This skill was practiced rst with Jodie still on the bolster.
Using the bolster allowed the therapist to facilitate weight
shifts and shoulder movements and inhibit hyperextension
of the trunk during efforts at movement. An adjustable
height table under which the bolster was slid helped to
support the switch. The switch position at rst was put
further back on the table than needed to require an
exaggerated forward weight shift to counterbalance the
extensor thrust that occurred when Jodie tried to move.
Remember at this point that Jodies arms were resting on
the table surface at midline so she would not have to move
her shoulder high or far laterally to place her hand on the
switch. The switch surface could be enhanced with a number of different materials (e.g., carpet samples, various
fabrics) to heighten differences between the table and
switch surfaces.
When Jodie was asked to activate the switch, a series
of short taps under her humerus were used to activate
humeral flexion (Figure 16-2), then laterally to bring the
humerus to the switch, which was placed slightly off to the
side (Figure 16-3). Active assistance in placing her hand
was also used alternatively to help Jodie develop a sense of
what was needed to get to the switch; however, this only
occurred on alternate attempts rather than each time she
tried to touch the switch.
360
CASE STUDY 2
A C HILD WITH LOW TONE
Two-and-a-half-year-old Lily has quadriplegic involvement
with low muscle tone and aimless movements of her limbs.
She can hold her head up and sit for short periods of time
(3 to 5 minutes) when placed in supported sitting but
spends much of her day playing in prone or supine, or
propped in her infant seat. She can grasp objects with
either hand but does not use both hands together. Most
of her activity consists of mouthing objects and then dropping them after briefly holding onto them. Her mother
reports her as being an irritable child who screams when
new stimuli come into the environment. The family would
like her to be able to play by herself for longer periods of
time and use both hands to play, to sit up longer so they
can play with her, to hold her cup and drink from it, and
for her to be less irritable. Box 16-3 contains examples of
goals for Lily. The goals of using her hands to hold a cup
will be used for demonstration purposes. Specically the
goal will be for Lily to sit supported in her high chair and
lift her cup and drink when it is placed on a surface in front
of her. Table 16-3 shows an activity analysis of this goal,
which is used to plan the intervention.
PREPARATORY ACTIVITIES
The intervention was scheduled for Lilys usual afternoon
snack time to locate the intervention in her usual daily
pattern of activities. Doing so offered demonstration time
and consistent feedback to the mother about Lilys performance and gave the therapist the opportunity to reevaluate Lilys skills each week. Table 16-4 illustrates the
steps of the activity and the techniques to be incorporated
into the intervention session. Because Lily was anticipating the cup, she tended to be less tolerant of extensive
prefeeding activity, so preparatory work was limited to 5
to 10 minutes. The therapist sat on a chair or sofa. Lily was
positioned on the therapists knees; she could either face
the therapist or face her mother with her back to the
therapist. Facing the therapist meant her base of support
was wider because she was straddling the therapists legs;
while facing her mother she was not straddling and the
base of support was narrower. Lily was supported at the
shoulders and the therapist gently bounced her using
BOX 16-3
Table 16-3
Activity analysis of drinking from a cup with two hands in supported sitting
Visual
Component
Auditory
Component
Movement
Components
Tactile
Component
Cup is placed on
surface; childs
arms activate at
the sight of the
cup
Sees cup
approaching and
set on surface
Person handing
the cup may make
statement; cup
makes sound as
it touches the
table
Kinesthetic
feedback from
the limb
moving
Takes cup
Humeral movement
is flexion; elbows
move into flexion;
ngers flexed
Feels cup
touch her
mouth; feels
weight of cup
on hands and
through
shoulders
May look at
others in the
room
Feels weight
of the cup in
her hands,
and liquid in
the mouth
and throat
Step of Activity
362
Table 16-4
Step of Activity
Movement Components
Facilitation/Inhibition Techniques
Cup is placed on
surface; childs arms
activate at the sight
of the cup
Takes cup
364
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Chapter
17
CHAPTER OUTLINE
PHASES OF WOUND HEALING
Phase I
Phase II
Phase III
EVALUATION OF THE CHILD WITH A HAND INJURY
Interview and History
Hand Range of Motion
Hand Strength
Hand Dexterity
Wound, Edema, and Scare
Pain
Hand Sensibility
Activities of Daily Living
TREATMENT OF TRAUMATIC HAND INJURIES IN
CHILDREN
Wrist Pain and Wrist Fractures
Fractures and Dislocations of the Digits
Tendon Injuries
Thermal Hand Injuries in Children
TREATMENT OF CONGENITAL HAND DIFFERENCES
Syndactyly
Radial Club Hand
SUMMARY
Observing a child at play makes it easy to understand
why the hand is one of the most frequently injured
body parts. Children must touch what they see and, if
the mind can conceive it, the hand will attempt it. The
hand is the primary instrument of discovery. Although
discovery is a function of the mind, it involves the eyes,
367
368
PHASE I
Names: Inflammatory, Clot, Substrate, Lag, or
Exudates Phase
Duration: From Wounding Up to 6 Days
Phase I prepares the wound for healing by cleaning
up debris, foreign material, and any devitalized tissue
caused by the trauma. It has both vascular and cellular
responses. Initially there is vasoconstriction followed by
vasodilatation. A clot is formed to prevent bleeding and
phagocytosis begins. The normal inflammatory phase
should be over in 5 to 6 days. However, a dirty wound,
in which the debris was not successfully cleaned up,
may develop into a subacute or chronic phase of
inflammation.
Clinical Signs
Redness: Vasodilation
Swelling: Increase of interstitial fluid
Pain: Nerve ending stimulation
Heat: Increase in blood flow
Hematoma: Trapped red blood cells creating a clot
decrease functional ability
Clinical Implications
The extremity is swollen and painful. Thus effort must
be made to decrease edema, control pain, and maintain
a clean environment. All affected joints should be placed
in a functional position if possible. The functional
position is one in which the wrist is in neutral to 20
degrees of extension, the metacarpophalangeal joint
(MP) is in 60 to 70 degrees of flexion, the interphalangeal joints (IPs) are extended, and the thumb is
in mid position between full abduction and full extension. Variations of this position depend on the injury.
This position must serve to both protect the wound
and to prepare the joint for future functional performance. Nonaffected joints should be free to move within
the constraints of the injury.
Physical agents can be used. An edematous hand in
the early phases of inflammation responds to cold to
help decrease the swelling. Cold constricts the vessels,
slowing down the active edema process; however, it is
rarely appropriate for the infant or toddler. For the
older child, physical agents must be selected carefully
to enhance healing. At later phase heat might be the
modality of choice for the same result. Heat dilates
the vessels. When the hand is placed in elevation with
PHASE II
The purpose of this stage is to rebuild damaged structures, and cover and strengthen the wound. There is
migration and proliferation of vessels for tissue repair.
Primitive healing occurs. The wound begins contracting from the outside in. This migration of cells is
limited by tension. Oxygen is needed for the healing
process. Four processes occur simultaneously in this
phase: epithelization, collagen production, wound contraction, and neovascularization.
Clinical Signs
Red granulation tissue
Beginning of wound contraction: Scars appear faster in
children than adults.
Moderate swelling may be present
Pain: Variable
Functional limitations
Clinical Implication
Clinical Implications
The clinical focus in Phase II is on decreasing scarring
and increasing mobility. Scar management is a challenge with children. If pressure garments are indicated,
the therapist may prefer to order a pressure garment
that covers more than just the hand to keep the garment on, and to allow even pressure throughout the
small body area. At the same time, motion must be
encouraged. With children, immobilization may extend
a week or two beyond the normal protocol if the repair
needs to be protected. Children regain motion rapidly
when presented with play situations after immobilization. Balancing immobilization and mobility requires
individual decisions based on the childs age and level
of maturity and severity of injury.
PHASE III
Names: Maturation, Scar Remodeling
Duration: End of Fibroplasia to 2 Years
In this phase, connective tissue matrix is remodeled.
Wound strength (tensile strength) may reach 50% of
normal by 4 to 6 weeks. Remodeling, which is a
370
BOX 17-1
PHASE I
Vasoconstriction
Vasodilation
Clot formation
Phagocytosis
PHASE II
Epithelization
Collagen production
Primitive wound contracture
Neovascularization (O2)
PHASE III
Maturation of scar
Collagen synthesis versus lysis
Collagen ber orientation and wound strength
Hand range of motion (ROM) is important for functional activities such as picking up and manipulating
objects, as well as touching and feeling. Total upper
extremity ROM is important in reaching into the environment. When measuring hand ROM, the therapist
also looks at total upper extremity movement, as well as
trunk and neck mobility. The hand is not separated
from the body in activity and therefore should not be
separated in evaluation.
When evaluating ROM in a hand injury or condition, close attention is given to tissue that obstructs the
motion. Ranges are reported, when possible, in several
ways so that the source of the limitation may be
identied. Passive range is the available motion intrinsic
to a joint when all extrinsic limitations are minimized.
If a tendon or scar is limiting the joint motion, place
the joint in a position of maximum biomechanical
advantage when measuring passive range so as to eliminate the extrinsic factors (Figure 17-1). For example, if
the flexor tendons are tight, flex the wrist when measuring passive MP motion.
Conversely, when measuring active motion, information is gained about the extrinsic structure that may
be limiting joint motion. Active motion may be divided
into functional motion, the motion available when the
child is asked to make a st or open the hand with no
limitations or instructions (Figure 17-2) versus blocked
motion, which refers to the motion available when
all proximal joints are put in neutral (biomechanical
advantage) to allow maximum force to be applied to
elicit the available motion of the joint being measured
(Figure 17-3).
For example, if measuring blocked proximal interphalangeal (PIP) flexion in a child with a flexor tendon
injury, put the wrist and MPs in neutral and ask the
child to flex his or her ngers. This provides informa-
Figure 17-1
Figure 17-3
Figure 17-2
tion about flexor tendon excursion. Placing the proximal joints in slight extension gives the flexors more
advantage. Always record where the proximal joint(s)
were placed during blocked measurements, so that
measurements can be repeated reliably. Finally, compare all ranges to determine which structure is limiting
the motion. Reliability of ROM is based on repeatability. The American Society of Hand Therapists (1992)
published a Clinical Assessment Recommendation
booklet that is an excellent resource for standardization
of measurements (Adams, Greene, & Topoozian, 1992).
Scheduling constraints and the childs cooperation
at times may limit the therapists ability to take comprehensive measurements. On these occasions, functional
measurements can be recorded. These measurements
have poor reliability because they are difcult to reproduce consistently. However, they do give some functional information about the use of the hand and thus
have value in some cases. Functional measurements
include:
Functional Flexion: (a) Ask the child to make a st;
measure the distance from the pulp of the digit(s) to
the distal palmar crease (Figure 17-4); or (b) ask the
child to make a hook, bringing the tips of the ngers
to the palmar digital crease; measure that distance.
Functional Opposition: Ask the child to touch the tip of
each nger to the thumb; measure the distance from
pulp of nger to pulp of thumb (Figure 17-5).
Functional Thumb Flexion: Ask the child to touch the
base of the small nger with the thumb, measure the
distance from the head of the 5th metacarpal to the
pulp of the thumb (Figure 17-6).
Functional Extension: Ask the child to extend the hand
against the table; measure the distance from the nail
to the table top (Figure 17-7).
372
Figure 17-7
Figure 17-5
Functional opposition.
Childhood (5 to 12 Years)
Measurement of specic range can be obtained at this
age, although it may be difcult. Observation of movement patterns that are consistent with in-hand manipulation that are present at this stage are helpful (Exner,
1992). The child can be asked to hold a spoon or turn
over a peg of a certain size in the hand, which provides
both functional and range information.
Figure 17-8
strength.
Figure 17-9
Clinical Implication
ROM helps determine which structure is the source
of the limitation. This information comes from measuring the difference between passive and active motion,
checking for unusual patterns such as intrinsic, web,
and ligamentous tightness. Active motion can be divided
into two types: (a) functional motion, motion the child
does on his or her own; and (b) blocked motion, motion
produced when the proximal joints are held in a position that gives maximum advantage to the distal joint.
The difference between measurements tells the therapist where the problem exists.
HAND STRENGTH
Hand strength is a function of the work of the muscles.
In measuring hand strength, we look at both specic
muscle strength and functional strength. Specic muscle strength is the measurement of each muscle tendon unit that is measured through manual muscle
testing, whereas functional strength is a measure of
muscles working together in a specic prehension
pattern and is measured with instruments such as a
dynamometer and pinch gauge. Functional measurements are divided into grip and pinch strength (Figs.
17-8 and 17-9). They are divided further into varying
grip sizes and different pinch patterns. Most commonly
tested pinch patterns are key pinch, pencil or three jaw
chuck pinch, and pad to pad pinch. With the handinjured population, functional strength measurements
are the most common. Although a variety of tools
exist for measuring strength, the most common are a
dynamometer for grip strength and a pinch gauge for
pinch strength.
374
HAND DEXTERITY
Dexterity as a component of function is described
as the ability to manipulate objects with the hands.
Accuracy and speed are the parameters of measurements for dexterity. Dexterity can be measured reliably
through established tests that have normative data on
the population tested. Dexterity may also be observed
when the child is picking up different size objects and
manipulating them (Aaron & Stegink Jansen, 2003).
Toddler
Dexterity is determined by watching the child manipulate small objects. In-hand manipulation skills (moving
an object within the persons hand) is noted at this age.
The therapist places a small object in the childs hand
and asks that it be turned over or moved around in the
hand. Video recording of the manipulation complements the testing procedure.
Early Childhood
Observation remains a staple of the evaluation procedure for this age group. The therapist observes how
the child approaches small objects, which hand is used
in grasp, grasp and release patterns, and sizes of manipulated objects. For more standardized testing, dexterity
tests such as the Functional Dexterity Test (FDT) may
be used. It is standardized for children ages 3 to 5 years
(Aaron & Stegink Jansen, 2003; Lee-Valkov et al., 2003).
For the age groups listed, the therapist observes for
the following information:
Are tasks or activities performed unilaterally or
bilaterally?
Is the hand being used spontaneously?
Is there indication of dominance? (Note: Hand dominance that appears too early may indicate a problem
with the nonpreferred side.)
Clinical Implication
Adolescence
Clinical Implications
Dexterity is a component of function that often is
overlooked in a hand evaluation. Dexterity information
is obtained by using standardized tests such as the FDT
or through observation.
3. Drainage. Note if there is any drainage. Use descriptive words such as minimal, moderate, or severe
for the amount of drainage, and bloody, sanguinous,
purulent, pus for the quality of the drainage.
4. Odor. An unusual odor may suggest infection or
presence of foreign material.
5. Temperature. Compare the temperature of the hand
or part to the other side. Warm or hot may indicate
infection or inflammation, whereas cool or cold
may point to a vascular insufciency.
6. Edema. Edema should be noted throughout the
healing process. Edema is measured with a tape
measure or volumeter. If the wound is open, the
tape measure must be sterile and the water in the
volumeter must be treated with a disinfectant.
When using a tape, landmarks are noted in the chart
for consistency of measurement. The skin should
not blanch when circumferential measurements are
taken with the tape. When using the volumeter
(a water displacement test), the hand is placed
straight-in so as not to displace more water than
necessary. The hand is lowered into the water until
the web space between the long and ring ngers
rests on the small peg at the bottom of the container. The volumeter usually is used with large
edematous areas and with older children. Descriptive words, such as hard, mobile, brawny, or pitting,
should be used for recording the type of edema.
7. Scar. Scar should be described as soft, thick, raised,
indurated, hard, or reactive. Depth, length, and
width of the scar should be measured and color and
vascularity should be noted. Sensitivity (or lack of)
of the scar should be recorded. Both a drawing and
a photograph of the scar should be taken if possible
(Baldwin, Weber, & Simon, 1992).
Clinical Implications
Open wounds, edema, and scar should be evaluated
and recorded on a regular basis. Photographs should be
taken when possible. The age of the child does not
change the evaluation procedure. However, in some
cases the evaluation process is challenging.
PAIN
376
HAND SENSIBILITY
Normal hand function requires normal sensibility, as
well as mobility and strength. Sensibility should be
screened in all children who can reliably communicate
information about the sensitivity of the hand. On the
initial screening, the therapist asks if the affected hand
feels the same as the unaffected hand. The therapist
then asks the child to report if there are differences in
feelings between the two hands as the therapist strokes
both hands. With vision occluded, the therapist touches
a nger and has the child tell what nger was touched.
The therapist moves the affected nger and asks the
child to mimic the movement with the other hand.
There are many creative ways to determine if the nerves
of the hand are viable. When this is not possible, information must be gained through observing the child use
the hand and noting sympathetic functions such as skin
color and texture, temperature, sweating, nail changes,
or hair growth. This helps the therapist determine if
there is a nerve problem. Stereognosis and graphesthesia are other forms of sensory screening in early child-
Clinical Implication
A thorough evaluation has a different meaning for each
diagnosis and age group. Many assessment tools are
available. Therapists must choose carefully and assure
that each evaluation looks at all components of function appropriate for the specic child, diagnosis, and
context. Evaluation is the road map for treatment and
progress.
TREATMENT OF TRAUMATIC
HAND INJURIES IN CHILDREN
Treatment of the pediatric population incorporates a
playful dimension. Couch, Deitz, and Kanny (1998)
reported on the role of play in preschool population.
They concluded that therapists must increase the
emphasis on play when evaluating or treating children.
Table 17-1
Right
Grip
Key pinch
Left
+
Pencil pinch
Fingertip
Index/middle
Ring/small
Dexterity
Volitional release
Comment
Sustained grasp
Functional reach to
Prehension Patterns
(Percent of normal)
Mouth
Back of neck
Fingertip pinch
Small of back
Key pinch
Hip
Other shoulder
Ball grasp
Head
Cylindrical grasp
Feet
Suitcase grasp
Other
Other
Continued
378
Table 17-1
Girth (cm)
Wrist
Specify ms tested
Proximal phalanx
Middle phalanx
Distal phalanx
Volumeter
Other
ADL: Dependent/mod assist/
minimal assist/independent
List
Sensation
Index
Middle
Ring
Small
Thumb
Palm
Tinels
Other
Comments
Order of Return
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
30 CPS
Heavy moving touch
Heavy touch
Temperature
Position sense
Light moving touch
Light touch
256 CPS
Moving 2-point
Static 2-point
A = Active
P = Passive
F = Functional
B = Blocked
1. Pain (1 Norm to
10 Painful)
2. Hypersensitivity
(1 Norm to 10 Sensitive)
Table 17-1
Range of Motion
WRIST
Palmar flexion
Dorsiflexion
Radial deviation
Ulnar deviation
Other
THUMB
Flexion MP
Extension MP
Flexion IP
Extension IP
Hyperextension IP
Palmar abduction
Radial extension (reposition)
Mid-position
Opposition (imp. rate)
Thumb to base 5th digit
Other description
Index Finger
Ring Finger
Flexion MP
Extension MP
Deviation/rotation
Flexion PIP
Extension PIP
Flexion DIP
Flexion MP
Extension MP
Deviation/rotation
Flexion PIP
Extension PIP
Flexion DIP
Extension DIP
Other description:
Long Finger
Extension DIP
Other description:
Small Finger
Flexion MP
Extension MP
Deviation/rotation
Flexion PIP
Extension PIP
Flexion DIP
Extension DIP
Other description:
Flexion MP
Extension MP
Deviation/rotation
Flexion PIP
Extension PIP
Flexion DIP
Extension DIP
Other description:
Opposition Thumb
to Fingertip (cm)
Index nger
Long nger
Ring nger
Small nger
Fingertip to Palmar
Crease (cm)
Index nger
Long nger
Ring nger
Small Finger
Fingertip to Palmar
Digital Crease (cm)
Index nger
Long nger
Ring nger
Small nger
Other description:
380
Evaluation
Types of assessments performed are dictated by the age
and cooperation of the child, as well as the attitude
and willingness of the parents or guardians. A com-
Figure 17-13
Cock-up splint.
Figure 17-14
Treatment
Above-elbow splint.
382
Figure 17-16
Figure 17-17
3.
4.
5.
6.
7.
Figure 17-18
home program and only occasional visits to the therapist for evaluation and update of home exercises.
8.
Evaluation
1. Observe the child from afar. Watch him or her use
the hand. The way the child uses the hand provides
information on pain and usage patterns. Is he or she
protecting it or using it? Is the child using the
affected digit when using the hand? If the thumb
is involved, is there a grasp and release pattern? Is
there sustained grasp?
2. Determine the childs demands on the hand under
normal conditions. Does he or she play sports or
participate in arts and crafts? Which is the dominant
hand? Interview the child (age dependent) and
Treatment
384
Figure 17-19
Figure 17-20
TENDON I NJURIES
Flexor Tendons
386
Figure 17-21
Figure 17-22
Figure 17-23
Figure 17-24
Figure 17-25
Discussion
The literature suggests many different approaches to
treating tendon injuries in children and adults. Kayli
and co-workers (2003) evaluated results of early mobilization of flexor tendon injuries in children ages 2 to
14, using above-elbow stabilization with a Duran-type
protocol. They reported favorable results with a mean
total active motion (0% to 100%) of 78.5%. They did
note that the age of the child and the presence of digital
nerve involvement affected the results (Kayli et al.,
2003). Fasching and co-workers (1998) looked at 90
severed digits in 38 children with the mean age of 4,
over a 4-year period. Children were all treated with the
Kleinert protocol. They had ve cases of tenolysis and
one rupture. In the remainder of the cases they had
88% good results and 2% poor results, which they
assessed based on Buck-Gramckos classication. They
concluded that excellent results can be achieved with
experienced therapists and informed parents. Grobbelaar
and Hudson (1994) reported 82% excellent results
based on Listers criteria in their sample of 38 children
(average age 6.7 years). They had no tenolysis and
388
Extensor Tendons
Zones I and II injury distal to the PIP (known as
mallet nger deformity) is discussed in the fracture
section of this chapter. Treatment for a tendon avulsion
from the distal phalanx is the same as the treatment
described for mallet nger deformity.
The literature shows little or no difference in treating extensor tendons with early protected motion
rather than immobilization. Immobilization is the treatment of choice in treating children of any age who
suffer an extensor tendon injury.
Immediately Postoperative Zones III to VII
(Phase I)
Splint the child with an extensor tendon injury in a
protective splint that has both a dorsal and volar component for better security and stability of the splint. For
Zone III injuries at the PIP level, a hand-based splint,
with the MPs at 20 to 40 degrees of flexion and the IPs
extended, is commonly used. The splint can go above
the wrist if it is feared that the child will not keep the
splint on. The splint should go above the elbow for
the young and unreliable child, with the elbow kept at
60 to 70 degrees of flexion; however, that is rare. For
all other zones, the forearm is neutral or pronated, the
wrist is in 30 to 45 degrees of extension, the MP joints
are kept at 30 to 60 degrees of flexion (depending on
the zone of injury), and the IPs are extended (including
the elbow if necessary to maintain the splint on the
child). The exact position depends on the stress on
the repair that can be determined intraoperatively and
communicated to the therapist.
The child should be followed in therapy at least two
times a week during the 3- to 4-week immobilization
phase. At each visit, the wound or stitches should be
cleaned, the dressing changed, gentle ROM should be
performed with all uninvolved joints, and protected
ROM may be performed with the involved joints
(patterns in extension only). Precautions should be
explained to the child, as well as the parents or guardians
about keeping the arm dry and clean, elevating the
extremity, and watching the color. The parents should
Figure 17-28
Extension lag.
Figure 17-29
390
are the most common, and children develop less stiffness than adults when immobilized. Children are curious and thus put themselves at risk. Common causes
for hand burns are hot cups of coffee, hot water, irons,
and heaters. The mechanism of injury and the nature
of the burn agent dictate the severity of the burn.
Sunburn can produce a supercial burn, whereas hot
water produces a scalding injury that can be supercial
or deep. A flame may result in full thickness burns (de
Chaliain & Clarke, 2000; Greenhigh, 2000).
Burns occur initially when there is direct contact
with a thermal agent, causing injury to the cellular
elements and structural proteins. Subsequently, there
is delayed damage secondary to progressive dermal
ischemia. When a child is exposed to heat, both the
temperature and the time exposed to the heat determine the extent of tissue damage (de Chaliain and
Clarke, 2000).
Palmar burns in toddlers are increasingly more
common. Dunst and co-workers (2004) reported an
alarming increase in palmar burns associated with gas
replaces.
Burns have been classied in four degrees, although
commonly only three degrees are referred to, as seen in
Table 17-2.
Rehabilitation of the burned hand should begin
immediately after the child has been medically stabilized because a 7- to 10-day delay may result in irreversible functional losses. The general goals of therapy
are to prevent deformity and maximize function (de
Chaliain & Clarke, 2000).
Intervention depends on the phase of healing.
Table 17-2
Classication
Depth of Penetration
Clinical Signs
First degree
Supercialepidermis level
Second degree
Supercial
Deep
Third degree
Full thickness
Fourth degree
Modied from de Chaliain T, Clarke HM (2000). Thermal and chemical injuries. In A Gupta, SPJ Kay, LRL Scheker, editors: The
growing hand, diagnosis and management of the upper extremity in children (pp. 665692). St Louis, Mosby.
392
Education
The parents or guardians and the child should be provided with information about the diagnosis, expected
outcomes, and steps to achieve these outcomes. In this
phase, education is primarily related to wound care,
dressing changes, positioning, pain management, and
limited activity. The parents or guardians are guided
through the rehabilitation process and included in all
therapy protocols. The importance of maintaining any
uncomfortable positions is emphasized. All precautions
are explained and reviewed. As indicated, the child is
encouraged to use the affected extremity in self-care as
much as possible.
General Comments
394
Clinical Implications
Children with hand burns should be seen by a therapist
early for positioning and gentle motion. Splint design
should be dictated by burn location. Children should
be followed until the scar has matured, which could
take up to two years.
TREATMENT OF CONGENITAL
HAND DIFFERENCES
There has been a lack of generally accepted nomenclature for the problem in children with congenital
differences of the hand. They have been called upper
limb or congenital anomalies, malformations, or differences. In this chapter, the word differences is used to
describe this population. Further classication of congenital differences has been devised by the International Federation of Societies for Surgery of the Hand
(IFSSH) (Swanson, Swanson, & Tada, 1983). This
BOX 17-2
I.
II.
III.
IV.
V.
VI.
VII.
International Federation of
Societies for Surgery of the Hand
Classification of Congenital
Differences
Failure of formation
Failure of differentiation of parts
Duplication
Overgrowth
Undergrowth
Constriction ring syndrome
Generalized abnormalities and syndromes
SYNDACTYLY
Syndactyly falls under the failure of differentiation
classication. It is a fusing of adjacent ngers that can
be simple (involving only skin) to complex (in which
the bones of two digits are fused). Syndactyly is one of
the most common hand deformities. It is found in
males more than females, and is present in 50% of cases
bilaterally. Often syndactyly is associated with other
problems, such as polydactyly, clefting, symbrachydactyly, or ring constriction. When these occur, surgery
and therapy should take these anomalies into account
when planning intervention. The goal of a syndactyly
surgical release is to create a functional hand with as
few surgical procedures as possible. Intervention can
be done as early as 6 months of age or even earlier,
especially in border ngers in which length discrepancy
is a concern. Full thickness skin graft is almost always
necessary for the soft tissue coverage after separation
and reconstruction (Smith & Laing, 2000; Dao et al.,
2004). Island flap reconstruction in incomplete syndactyly has been advocated by Brennen and Fogarty
(2004), in which skin and fat are rotated for coverage,
with good results, minimal scarring, and rare need for
follow-up skin grafting (Dao et al., 2004).
Figure 17-36
foam.
Phase III
Figure 17-34
Figure 17-35
396
Clinical Implications
Children that have had syndactyly releases should be
seen in therapy for positioning and scar management
immediately postoperatively. AROM and functional
patterning should be initiated as soon as the grafts or
flaps are healed.
Function
Functional limitations vary based on the severity of the
radial club hand, as well as the childs age and adaptation to the condition and environment. Clinicians must
be cautious not to assume functional limitations based
Figure 17-37
Figure 17-38
398
Clinical Implications
When treating a child with congenital differences, the
assessment should be based on the specic child and
his or her adaptation, rather than typical children of the
same age. Often children adapt beautifully to their
differences and minimal intervention is necessary.
SUMMARY
This chapter has provided a base line for the healing
process for common injuries or surgical interventions.
The process of evaluation also has been discussed, as
well as common treatment protocols. With each injury
or condition the actual treatment plan is individualized
to the specic child and his or her special situation
based on the evaluation. Knowledge of normal development, normal healing, and good observation skills
may be the most valuable evaluation tools, especially
with infants and small children. Gaining the childs
trust and helping him or her overcome fear is the rst
step in therapy. After an injury or surgery, the child may
regress in development and adaptive skills. The parents
or guardians also may be fearful and confused as to
what is happening to the child. Each child presents
with unique qualities. When determining a treatment
plan, these qualities are considered, along with the
childs home environment, diagnosis, and the type of
medical intervention received. Realistic functional goals
are then formulated that are specic to that child.
Children are resilient and bring new meaning to the
notion of what is possible rather than impossible.
REFERENCES
Figure 17-39
400
Chapter
18
CHAPTER OUTLINE
SPLINTING PRINCIPLES
401
402
SPLINTING PRINCIPLES
Mechanical principles used in splinting adults and children are the same. Once the concepts of the anatomical
and mechanical principles are understood there is little
requirement for splint patterns. Applying the softened
splint material and positioning the hand and affected
joints in the desired and optimal biomechanical position for the purpose the splint is intended are the keys
to effective splinting. Generally, the experienced therapist uses less splint material without a pattern than a
novice splinter with a pattern because it takes both
perception of what the splint will do and what forces
the splint will exert, as well as the vision of how the
splint will accomplish this to be an effective and efcient splint maker. The splint is used to place body
parts into the most benecial position for the preestablished goal with proper biomechanics considered
for the extremity, injury, and splint.
The mechanical principles that must be understood
and applied include force, pressure, torque, friction,
and shear stress. Obviously an entire chapter could be
dedicated to biomechanics and mechanical principles;
instead an overview of the important mechanical prin-
9
2
5
2
3
6
8
9
404
BOX 18-1
Position
Function
Hygiene
Protection and behavior
SPLINT SELECTION
THE PROBLEM-BASED SPLINT
SELECTION C HART
Hogan and Uditsky (1998) have developed a priority
rating form, as well as a splint selection flow chart
(Figure 18-3), which is helpful for determining the
Figure 18-3 The Pediatric Splint Selection Flow Chart. (From: Hogan T & Uditsky T [1998]. Pediatric splinting: Selection, fabrication, and clinical
application of upper extremity splints. San Antonio, TX, Therapy Skill Builders. p. 20.)
406
Table 18-1
Table 18-1
(Modied from: Hogan L & Uditsky T [1998]. Pediatric splinting: Selection, fabrication, and clinical application for upper extremity
splints. San Antonio, TX, Therapy Skill Builders. p. 31.)
408
Figure 18-4
. . . the rst step is to dene the object of the dynamic splint for
the specic hand we are treating and for the specic joint or
joints that we want to mobilize or modify. Then we should ask 10
questions in relation to the forces we propose to use: (1) How
much force? (2) Through what surface? (3) For how long? (4) To
what structure? (5) By what leverage? (6) Against what
reaction? (7) For what purpose? (8) Measured by what scale? (9)
Avoiding what harm? and (10) Warned by what signs?
(Brand, 2002, pp. 1811-1817).
Proliferative
Remodeling
Immobilization
o Static
Mobilization
o Dynamic
o Serial Static
o Static Progressive
Restriction
o Static
o Dynamic
BOX 18-2
410
Each material also is made up of a different combination of plastic, rubber, and polymers and the qualities
also are influenced by the thickness of the material.
Materials come in 1/16, 1/12, 3/32, and 1/8 thickness.
Most nger-based splints are made from the thinnest
1
/16 materials to help reduce bulk between the ngers
and they are strong enough to maintain the correct
position in a nger. Childrens hand or wrist splints can
be made from this material as well if spasticity is not an
issue. However, hand, wrist, and forearm splints should
be made from thicker materials so they will retain their
strength across the joint.
Other physical characteristics include the option of
perforations, as well as color. Many splinting materials
exist and new ones come on the market all the time. It
is a good learning experience to have your local sales
representative bring out or send you samples of the
various materials in different thicknesses. Different splint
property charts go into great detail about the materials,
but the best way to nd out how they will respond to
your use of them is hands-on use. Play with the different materials and make the same splint out of several
types and thicknesses of material. Use different
strapping materials as well and you will nd out what
works best for the most common splint types you
make. If you work in a busy hand clinic you most likely
have several different types of materials in various
thicknesses because of the wide variety of hand and
upper extremity diagnoses seen. The school, itinerant,
or home health therapist may nd that he or she is
making a similar type of splint for a similar age group
and may select a couple of all-around good splint materials to have on hand. Remember not to leave them in
the car! This is an expensive mistake for a traveling
therapist, as the author learned from personal experience during one hot Texas summer. Soft splinting
materials also are splints by denition. This includes,
but is not limited to, Neoprene, Lycra, elastomer,
strapping, and taping. Combinations of conventional
splint and soft materials may be the best choice, depending on the specic needs of the child.
FISTED HAND
The sted hand is difcult to distinguish in infants
because the palmar grasp reflex is strong. This is easier
to discern when looking at symmetry of the upper
extremities. It may be appropriate to provide an antispasticity cone or soft cone if the hand does not open
to explore or grasp in an age-appropriate pattern.
Infant splints are tiny, and fabricating these miniature
splints is an art in itself. It is perfectly ne to cheat
and fabricate on the opposite hand and flip the
splint, or look for a sibling or another similar-sized
infant on which to fabricate the splint. In the older
child the sted hand can be a problem for function, as
well as hygiene. The least restrictive splint is always the
better choice; however, extra strapping or including
proximal joints may be necessary for splint security and
the prevention of splint distal migration.
For younger toddlers and pre-school-aged children,
weight bearing on their upper extremities requires wrist
and nger extension. A clamshell or bivalved splint
provides both wrist and hand control during weightbearing activity. Splint material plays a bigger part in
this splint than in others. Flexor tone and sting can
immediately ruin a beautiful piece of soft Polyflex II by
turning it into a squashed-up clump of material when
applied to a sensitive or tactilely defensive hand. A
more rigid splint material with more memory, such as
A
B
Figure 18-10 A, Elastomer used as a splint base for a 2-month-old infant with fisted hand and thumb in palm.
Strapping is made of neoprene and is run through slits in the material. (Splint courtesy KG Staines, Hand Care of Houston.)
B, Adapt-It pellets used to form finger separation and control alignment within a resting splint.
412
Figure 18-11 A, Fifteen-year-old child. with athetoid cerebral palsy demonstrating adducted thumb. B, ThumbDuction
strap on child to improve resting posture. C, ThumbDuction strap used to stabilize thumb carpometacarpal joint while
working on strengthening and manipulation activity.
Ezeform or Aquaplast, allows some touching of material to itself without instant bonding. The nished
splint also has fewer ngerprints and rough edges. It
also may be easier to use precooled Thera-Band or Ace
wrap for a proximal third hand or to complete the
proximal forearm shape and then reheat only the distal
or hand part of the splint that will be shaped for the
hand. This is a useful splint for supervised weightbearing activities. Because there is progression, the
dorsal part of the splint can be used alone with individual nger strapping, which provides tactile and
kinesthetic input through the palm. With spasticity in
the upper extremities and hands, the position obtained
with the antispasticity ball or cone helps reduce tone
(Figure 18-13). In the most severe of hand contractures, in which the goal is to prevent skin breakdown
and maintain hygiene, the Freedom Finger Contracture
WRIST FLEXION
The wrist is considered the key to the hand because
the hand is dependent on the wrist for correct placement and stability to allow nger motion. It is crucial
that the wrist be controlled to allow the ngers and
thumb freedom. The optimal wrist position for nger
function is 25 to 30 degrees of wrist extension. To
allow maximum tactile input, dorsal splinting is preferred; however, pressure on a thin or bony wrist can
become uncomfortable and cause skin breakdown.
There are as many prefabricated and precut wrist splints
as there are ideas for custom designs. If one splint
414
Figure 18-15 A, Wrist cock-up splint fabricated for post wrist trauma in a young girl. (Splint courtesy KG Staines, Hand
Care of Houston.) B, Prefabricated cozy wrist splint, with washable terry cover. The wrist support and hand rest can be
bent to fit.
A
B
Figure 18-17 A, Four-year-old with athetoid cerebral palsy, unable to weight bear on open palm. B, Splint fabricated
to assist in supervised weight-bearing activities. Adapt-It pellets used to support the palmar arches while weight bearing.
C, Child in side sitting with weight-bearing splint on right hand.
416
FRACTURES
Many nonoperative pediatric fractures are not even
seen by therapists because the patients are doing well
by the time they have their cast removal follow-up with
the orthopedic physician. Postoperative fractures, on
the other hand, may nd their way to your clinic.
Percutanous pins and external xators can be protected by splinting circumferentially with bivalved or
clamshell splinting. The zipper splint is an excellent
after cast splint because it is circumferential and rigid
(Figure 18-20).
Buddy taping or buddy strapping usually is effective
to encourage movement in a stiff nger after immobilization. Taping stays on better, but parents or caregivers should be instructed in how to apply it because
it does get dirty. Buddy straps are more easily removed
418
J UVENILE ARTHRITIS
As with adult onset arthritis, the patient with juvenile
arthritis requires rest of inflamed joints and tissue.
Although there are many classications of juvenile
arthritis, the joint problems and functional task problems are similar. Resting hand splints for night splinting
to rest the joints in the functional position is a good
preventive measure. Thumb carpometacarpal splints to
support the thumb are practical to prevent fatigue if the
hands are involved (Figure 18-21). Functional splints
for handwriting and computer keyboarding use also are
benecial if the school-aged child will wear them in
front of peers. For swan neck (Figure 18-22) and
boutonnire (Figure 18-23) deformities, the same
splint design as that used in adults can be employed.
Proper alignment early on helps prevent joint contractures, which, when present, are more difcult to treat.
GENERAL CONSIDERATIONS IN
PEDIATRIC HAND SPLINTING
WEARING SCHEDULE FOR PEDIATRIC SPLINTS
The wearing schedules for splints depend on the diagnosis and rationale for the splint. As with adult splinting, soft connective tissue responds better to low-load
prolonged stress (LLPS) than high-load brief stress
(HLBS). This has been documented time and again in
scientic papers, as well as clinical research for exercise
physiology and splint-wearing time (Austin & Jacobs,
2003; Gabriel, 1996; Hogan & Uditsky, 1998). Paul
Brand was one of the rst to apply this to splinting. He
coined the term inevitability of gradualness. Dr. Brand
was a physician and missionary who worked to make a
difference in the quality of life of Indian children born
with club feet that were never treated and were limited
in mobility and social status by the time they became
adults. In treating these infants, he allowed the child to
nurse while seated in its mothers lap as he gently
pulled the foot toward normal alignment. If the infant
looked up but continued sucking, that was where the
foot was casted; if the baby stopped sucking and started
to cry, they had gone too far. This type of serial casting
was effective in remodeling soft tissue. Progress was
maximized without tearing tissue and the results of the
gentle but end-range stretching improved the outcome
of many of these infants. Flowers and Michlovitz (1988)
introduced the term total end range time (TERT)
through further research in this same area of soft tissue
adaptability. TERT is the frequency multiplied by the
duration when at end range. This also has evolved with
splinting to promote low-load prolonged stress. Three
factors play a role in deciding wearing schedules: frequency, duration, and intensity of force. If the child
initially wears the splint 20 minutes three times a day,
the TERT is 60 minutes. If the intensity of force is too
low there is no advancement in joint motion; however,
it is necessary to allow the child and soft tissue to adapt
and accommodate to the splint and the stretch it is
providing. Slowly add to the wearing time by increasing
both the frequency and duration. It must be compatible with the childs and parents lifestyle and activities
that are appropriate. The Appendix to this chapter
includes a Splint Care Handout, which includes use,
wear, and care instructions, as well as precautions and
SUMMARY
In conclusion, when splinting the child, remember to
problem solve and prioritize the problems. The goals
of splinting vary and may be intended to promote
joint functional position or assist in holding an eating
or writing utensil. One must keep in mind the normal
conguration and architecture of the hand whether to
prevent contractures or help restore soft tissue length
after an injury. A well-designed splint should provide
the needed support or restriction without interfering
with normal exploration and movement patterns.
Children who have not experienced normal movement
patterns with grasp, release, or weight bearing may gain
new information from their environment with the use
of splints; however, sometimes the right answer is no
splint. Splinting is a science, as well as an art. Once
mastered, splinting is a great instrument to have in your
therapy toolbox when treating children. Enjoy the
journey.
420
BOX 18-3
Anti-Houdini Techniques
422
I
J
CASE STUDY
A C HILD WITH RADIAL N ERVE PALSY
Carlos is an active 4-year-old child who fell off the monkey
bars and sustained a Type III complete, displaced left
supracondylar humerus fracture. The fracture was closed
reduced and xed with two K-wires under C-arm
guidance by an orthopedic surgeon the next day.
Progressive high radial nerve palsy was apparent when the
cast was removed at 4 weeks postoperatively. Carlos was
referred to therapy 3 months later. Initially he had no
active wrist extension and when digital extension was
attempted the unopposed long flexors created a claw
deformity (Figure 18-27). He was not using the extremity
to play, feed, or dress himself. The radial nerve splint was
fabricated to hold the wrist in extension and balance the
wrist and digital extensors with the strong flexors and still
allow full nger flexion and grasp, as well as sensory and
tactile input through the palm (Figure 18-28). This is a
dorsal splint fabricated with 3/32 Polyflex II. The nger
B
A
Figure 18-28 A, Volar view of radial nerve splint using Thera-tubing for digital support. B, Dorsal view of radial
nerve splint. C, Maximum extension effort with splint on. D, Maximum flexion effort with splint on.
424
A
B
Figure 18-29
426
ACKNOWLEDGMENTS
Special thanks to Otto, Eric, Karl, Stefan, mom and
dad, Gloria Gogola, Trent Carlyle, Kimberly Staines,
Jean Polichino, Karen Lahvis, and the girls. Also, the
Spanish version of Appendix 18B is courtesy of A.
Galindo.
REFERENCES
Anderson L, Anderson J (1988). Hand splinting for infants
in the intensive care and special care nurseries. American
Journal of Occupational Therapy, 42(4):222226.
Austin N, Jacobs M (2003) Splinting the hand and upper
extremity: Principles and process. Philadelphia, Lippincott
Williams & Wilkins.
Birch R, Chir F, Achan P (2000). Peripheral nerve repairs and
their results in children. Hand Clinics, 16(4):579595.
Brand P (2002). The forces of dynamic splinting: Ten
questions before applying a dynamic splint to the
hand. In J Hunter, E Mackin, A Callahan, T Skirven,
L Schneider, L Osterman, editors: Rehabilitation of the
hand and upper extremity (pp. 18111817). St Louis,
Mosby.
Byron P (2002). Splinting the hand of a child. In J Hunter,
E Mackin, A Callahan, T Skirven, L Schneider, L
Osterman, editors: Rehabilitation of the hand and upper
extremity (pp. 19141919). St Louis, Mosby.
Cunningham MW, Yousif NJ, Matloub HS, et al. (1985).
Retardation of nger growth after injury to the flexor
tendons. Journal of Hand Surgery, 10:115117.
Fess EE (2002a). A history of splinting: To understand the
present, view the past. Journal of Hand Therapy,
15:97132.
Fess EE (2002b). Principles and methods of splinting for
mobilization of joints. In J Hunter, E Mackin, A
Callahan, T Skirven, L Schneider, L Osterman, editors:
Rehabilitation of the hand and upper extremity
(pp. 18181827). St Louis, Mosby.
Fess EE, Gettle K, Philips C, Janson J (2005). Hand and
upper extremity splinting: Principles & methods, 3rd ed.
St Louis, Mosby.
Flowers KR, Michlovitz SL (1988). Assessment and
management of loss of motion in orthopedic dysfunction.
In Postgraduate advances in physical therapy (pp 1-11).
Alexandria, VA: American Physical Therapy Association.
Gabriel L (1996). Splinting children who have
developmental disabilities. In B Coppard, H Lohman,
editors: Introduction to splinting: A critical thinking and
problem-solving approach. St. Louis, Mosby.
Hogan L, Uditsky T, (1998) editors: Pediatric splinting:
Selection, fabrication, and clinical application of upper
extremity splints. San Antonio, TX, Therapy Skill Builders.
Kinghorn J, Roberts G (1996).The effect of an inhibitive
weight-bearing splint on tone and function: A single-case
study. American Journal of Occupational Therapy,
50(10):807815.
Osterman L, Paksima N (2002). Flexor tendon injuries and
repair in children. In J Hunter, E Mackin, A Callahan, T
Skirven, L Schneider, L Osterman, editors: Rehabilitation
of the hand and upper extremity (pp. 19071913). St
Louis, Mosby.
SUGGESTED READING
Barnes KJ (1986). Improving prehension skills of children
with cerebral palsy: A clinical study. Occupational Therapy
Journal of Research, 6(4):227239.
Bell-Krotoski J (2002). Plaster cylinder casting for
contractures of the interphalangeal joints. In J Hunter, E
Mackin, A Callahan, T Skirven, L Schneider, L Osterman,
editors: Rehabilitation of the hand and upper extremity
(pp. 18391845). St Louis, Mosby.
Brand P (1985) Clinical mechanics of the hand. St Louis,
Mosby.
Brand P (2002) Lessons from hot feet: A note on tissue
remodeling (1944), Correspondence from Dr. Brand to
Elaine Ewing Fess, MS, OTR, FAOTA, CHT about soft
tissue remodeling process. Journal of Hand Therapy:
Splinting Special Issue, 15:133135.
Colditz J (2002) Anatomic considerations for splinting the
thumb. In J Hunter, E Mackin, A Callahan, T Skirven, L
Schneider, L Osterman, editors: Rehabilitation of the
hand and upper extremity (pp. 18581874). St Louis,
Mosby.
Colditz J (2002). Plaster of Paris: The forgotten hand
splinting material. Journal of Hand Therapy,
15(2):144157.
Exner CE, Bonder BR (1983). Comparative effects of three
hand splints on bilateral hand use, grasp, and arm-hand
posture in hemiplegic children: A pilot study. The
Occupational Therapy Journal of Research, 3:7592.
Fitoussi F, Mazda K, et al. (2000). Repair of the flexor
pollicis longus tendon in children. The Journal of Bone &
Joint Surgery, 82(8):11771180.
Glasgow C, Wilton J, Tooth L (2003). Optimal daily total
end range time for resolution in hand splinting. Journal
of Hand Therapy, 16(3):207218.
Greenhalgh D (2000). Management of acute burn injuries
of the upper extremity in the pediatric population. Hand
Clinics, 16(2):175186.
Keren O, Shnarch-Voda M, Barak D, Behroozi K (2003). A
therapeutic splint for hypertonic flexed elbow in upper
motor neuron diseased patients. Prosthetics and Orthotics
International, 27:6368.
Lee M, LaStayo P, vonKersburg A (2003). A supination
splint worn distal to the elbow: A radiographic,
electromyographic, and retrospective report. Journal of
Hand Therapy, 16:190198.
Lin SC, Huang TH, Lin CJ, Hsu HY, Chiu HY (1999). A
simple splinting method for correction of supple
congenital clasped thumbs in infants. Journal of Hand
Surgery (Br) 24(5):612 614.
Lohman M (2001) Antispasticity splinting. In B Coppard,
H Lohman, editors: Introduction to splinting: A criticalthinking & problem-solving approach (pp. 326349). St
Louis, Mosby.
MacKinnon J, Sanderson E, Buchanan J (1975). The
MacKinnon splinting: A functional hand splint. Canadian
Journal of Occupational Therapy, 42(4):157158.
Appendix
18A
SPLINT INSTRUCTIONS
Name________________________________________________
Splint type_______________________
Date__________________
Goal of splint______________________
______________________________
Patient or Parent (if under 18)
____________________________
Therapist
429
Appendix
18B
CUIDADO DE LA FRULA
Nombre ______________________
Dato ________________
Frula ______________________
Firma _____________________________________
430
Terapista _______________________________________
Appendix
18C
LIST OF VENDORS
1. Alimed Inc.
297 High Street
Dedham, MA 02026-9135
(800) 225-2610
www.alimed.com
2. Benik Corporation
11871 Silverdale Way NW #107
Silverdale, WA 98383
(800) 442-8910
www.benik.com
3. DeRoyal/LMB
200 DeBusk Lane
Powell, TN 37849
(800) 541-3992
www.deroyal.com
7. 3-Point Products
1610 Pincay Court
Annapolis, MD 21401
(888) 378-7763
www.3pointproducts.com
431
Chapter
19
EFFICACY OF INTERVENTIONS TO
ENHANCE HAND FUNCTION
Jane Case-Smith
CHAPTER OUTLINE
433
434
Table 19-1
II
III
IV
Expert opinion
Theories based on basic science. Adapted from Butler and Darrah (2001), Law (2002), and Phillips and co-workers (1998).
The rst section of this chapter describes interventions for children with cerebral palsy (CP) who had
moderate to severe hand function limitations. The
second section describes interventions for children with
developmental coordination disorder and milder hand
function limitations. The third section describes
research of handwriting interventions. A summary discusses issues in research of hand skill interventions and
future directions for research.
CHILDREN WITH
CEREBRAL PALSY
CP is a nonprogressive posture and movement disorder
that results from a brain lesion around the time of
birth. CP is a common disorder (2 in 1000) (Behrman,
Kleigman, & Jenson, 2000), and its clinical picture
varies greatly. Lifelong medical and functional problems are associated with cerebral palsy and are well
described in Chapter 16. Most individuals with CP
have problems in hand function, characterized by weakness, spasticity, incomplete isolation of nger movements, and sensory impairments (Duff & Gordon,
2003). Bly (1983) explained that in children with CP,
436
Table 19-2
Authors
Level of
Evidence
Sample
Intervention
Measures
Findings
Barnes (1989a)
Level IV
AB single
subject
N=3
spastic cerebral
palsy (CP)
46 years
Weight bearing on
extended arms; 1920
sessions
Erhardts
assessment of
prehension
Visual analysis.
Prehension
skills improved
in two subjects.
Barnes (1989b)
Level IV
AB single
subject
N=3
spastic CP
5.97.5 years
Weight bearing on
extended arms;
4 sessions/wk for 10 wk
Erhardts
assessment of
prehension
Visual analysis;
two of three
improved
Level III
ABA cohort
design
N = 10,
spastic CP
Videotape of
reach, grasp,
release. Hand
weight-bearing
surface area
Hand surface
increased.
Reach did not
improve. Grasp
and release
improved.
Level IV
ABA single
subject
N = 1, spastic
quadriplegia
CP
Use of a weight-bearing
splint; 8 wk baseline,
8 wk treatment, 8 wk
baseline
Hand surface
area and play
activities did
not improve.
Arm position
did improve.
Level IV
ABAB
N=2
spastic diplegia
27, 32 months
Analysis of
dressing in
shirt, socks,
jackets
No difference
between play
and NDT
effects
DeGangi (1994)
Level IV
case study
N = 3, one
spastic diplegia,
one spastic
quadriplegia,
one hemiparesis
Individualized NDT
techniques, 2/wk for
8 wks
Substantial
gains in all
skill areas
Level III
multiple
crossover
N = 8, spastic
quadriplegia
1015 years
Upper
extremity
movement
using kinematic
analysis
Changes were
not signicant
for NDT
alone; were
signicant for
treatments
combined.
Table 19-2
Sample
Intervention
Measures
Findings
Level I
randomized
clinical trial
79 children
with spastic
CP
PDMS-FM
QUEST
ROM of wrist
PDMS: not
signicant;
QUEST, more
improved for
children who
wore casts
Level I
crossover
with
washout
N = 50 spastic
CP, with
moderatesevere UE
impairment,
18 months
4 years
PDMS-FM
QUEST
No difference
among
treatment
types
Cruickshank &
ONeill (1990)
Level IV
case study
N = 1, spastic
quadriparesis,
11 years
Range of
motion
(ROM)
ROM
increased with
plaster cast
and decreased
with berglass
cast.
Level IV
cohort study,
pre- and postmeasures
N = 11,
hemiplegic and
quadriplegic
CP, 518 years
ROM, muscle
tone, progress
on goals
ROM
increased and
muscle tone
decreased
immediately
after casting.
At 6-month
follow-up;
ROM
maintained;
some hand
function goals
achieved.
Level IV
ABA
N = 1; CP,
age = 8 years
Functional
activities;
modied
Ashworth
Scale; resistive
movement
Reduced
spasticity
immediately,
but not long
term.
Level IV
single
subject
AB
N = 1.
moderate
spastic
quadriparesis,
age = 4 years
ROM, grip
strength,
dexterity, and
prehension
patterns
ROM,
dexterity,
quality of
movement
improved;
strength did
not.
Authors
Continued
438
Table 19-2
Authors
Level of
Evidence
Reid &
Sochaniwskyj
(1992).
Sample
Intervention
Measures
Findings
Level II
alternative
treatments
N = 10,
children with
CP with upper
extremity
involvement
Quality of
movement in
reaching,
movement
latency, time,
average
velocity, and
movement
units
No signicant
differences
with or
without the
splint
Level III
ABA
N = 2,
hemiparesis;
ages = 2 and
3 years
Constraint-induced
(CI) therapy, wore a
splint for 3 weeks,
2 weeks before and
after were baseline,
with 6-month follow-up
Analysis of play
session for
how often
children used
involved hand
Use of involved
hand doubled.
Improvements
in grasp,
release, and
sensory
exploration
were signicant.
Charles, Lavinder,
& Gordon (2001)
Level IV
AB design
N = 3,
hemiparesis CP
CI therapy, wore a
sling 6 h/day for
14 days
Manual
dexterity,
strength
sensory
discrimination,
bilateral
coordination
Hand function
improved in
2 or 3 children;
sensory
discrimination
improved in all;
coordination
of force
improved in 1.
DeLuca, Echols,
Ramey, & Taub
(2003)
Level IV
case study
N = 1,
hemiparesis
CP, age =
15 mo
CI therapy, wore a
bivalved cast for 2 weeks
PDMS-FM,
DDST,
Pediatric
Motor Activity
Log, Toddler
Arm Use Test
All scores
improved
signicantly
and used
involved arm
100% in free
play.
Pierce, Daly,
Gallagher,
Gershkoff, &
Schaumburg (2002)
Level IV
case study
N = 1,
hemiparesis
CP, age =
12 years
CI therapy, plus
62-hour sessions of
OT/PT
Wolf Motor
Function Test,
Assessment of
Motor and
Process Skill
(AMPS);
8-month
follow-up
Scores
improved for
the Wolf
Motor
Function Test,
AMPS, and
increased use
of involved
arm by selfreport.
Table 19-2
Authors
Level of
Evidence
Sample
Intervention
Measures
Findings
Willis, Morello,
Davie, Rice, &
Bennett (2002)
Level I
randomized
clinical trial;
crossover
design
N = 25,
hemiparesis
CP, ages =
18 years
PDMS-FM,
parent report
PDMS-FM
improved
signicantly,
more in CI
group than
control group;
21 of 22
parents
reported
improvement
at follow-up
Taub, Ramey,
DeLuca, & Echols
(2004)
Level I
randomized
clinical trial
N = 18,
hemiparesis
CP, ages =
7 mo to 8 yrs
CI therapy; children
wore bivalved casts and
received 6 hours of
therapy for 21 days or
conventional therapy.
Pediatric
motor activity
level (PMAL)
Toddler Arm
Use Test
(TAUT)
Large gains
with CI
therapy, TAUT
and PMAL
improved
signicantly.
Gains were
maintained at
3- and 6months
follow-up.
Dudgeon, Libby,
McLaughlin, Hays,
Bjornson, &
Roberts (1994)
Level IV
pre- and
postintervention
with
follow-up
N = 29,
spastic CP
Selective dorsal
rhizotomy with
postoperative physical
and occupational
therapy
Pediatric
Evaluation of
Disability
Inventory
(PEDI);
reach and
coordination,
6- and 12month
follow-up
Children with
diplegia
improved in
functional
mobility and
self-care on
the PEDI. Did
not improve in
reach and
coordination.
Loewen, Steinbok,
Holsti, & MacKay
(1998)
Level IV,
pre- and
post-surgery
with
follow-up
N = 37,
spastic CP;
age mean =
4.1 yrs
Selective dorsal
rhizotomy
Quality of
Upper
Extremity
Skills Test
(QUEST),
WeeFIM, 1
year after
surgery
Signicant
gains on both
scales
Mittal, Farmer,
Al-Atassi, et al.
(2002a)
Level IV
pre- and
post-surgery
with 3 and
5 year
follow-up
N = 57, 41 at
3 years, and
30 at 5 years,
spastic CP,
35 years
Selective dorsal
rhizotomy
PEDI
Self-care and
mobility
increased
signicantly
at 3 and
maintained at
5 years.
Continued
440
Table 19-2
Authors
Level of
Evidence
Sample
Intervention
Measures
Findings
Mittal, Farmer,
Al-Atassi, et al.
(2002b)
Level IV
pre- and
post-surgery
with
follow-up
N = 70 at
post-op, 45
at 3 years and
25 at 5 years;
spastic CP, 3
to 7.4 years at
the time of
surgery
Selective dorsal
rhizotomy
PDMS-FM
Signicant
gains at 3 years,
maintained at
5 years
Albright, Gilmartin,
Swift, Krach,
Ivanhoe, &
McLaughlin (2003)
Level IV
prospective
case series
study with
no control,
3-month
follow-up to
70 months
68 children
with spastic
CP, 73% were
younger than
16 years
Intrathecal baclofen
Ashworth
scales for
spasticity
Spasticity
decreased
signicantly
and remained
decreased for
up to 10 years.
Wallen, Oflaherty,
& Waugh (2004)
Level IV
prospective
case series
study with
no control,
3- and
6-month
follow-up
16 children
with spastic
CP
Botulinum toxin
(BOTOX)
Canadian
Occupational
Performance
Measure
(COPM),
Goal
Attainment
Scale,
Assessment of
limb function,
Child Health
Questionnaire,
parent
questionnaire,
Modied
Ashworth
Scale, ROM
Improved on
COPM, no
change on the
assessment of
limb function
or Child
Health
Questionnaire,
reduction of
muscle tone
that returned
to baseline at
6 months. No
change in
ROM.
N EURODEVELOPMENTAL TREATMENT
The effectiveness of NDT has been researched for the
past 30 years. A number of these studies have used true
442
Splinting
Splints have been designed to reduce hypertonicity
and improve function in children with CP. Exner and
Bonder (1983) evaluated three different splints on a
group of 12 children using a counterbalanced research
design. Each of the splints had signicant positive
effects. The orthokinetic and MacKinnon splints demonstrated a greater effect than the short opponens; however, the former are rarely used in practice today.
Although the short opponens was less effective in
improving grasping skill, at present it is commonly
444
Clinical Trials
Two randomized clinical trials of CI therapy have been
completed. Willis and others (2002) implemented a
study using 25 children with hemiparesis. A crossover
design was used. A plaster cast was applied to the
unaffected arm of the treatment group and was not
removed for 1 month. The control group received no
treatment. Fine motor skills of both groups were measured using the PDMS-FM before and after intervention. At 6 months after the rst intervention the
control group (N = 10) received the intervention and
the group previously casted served as a control. For the
rst intervention period, changes in PDMS-FM scores
were signicantly different, with gains by the intervention group much higher than gains by the control
group. These changes were sustained when measured
6 months later. The second group (who began CI
therapy at 6 months) also made signicant gains with
intervention. Parents globally reported improved use of
the affected arm. Several children did not tolerate the
casts and the parents asked that they be removed.
Taub and co-workers (2004) also completed a
randomized trial (Level I) using 18 children. The CI
therapy involved two components. The children in
the intervention group were casted and the cast was
bivalved for easy removal weekly. The intervention
group also received 6 hours of therapy each day, implemented by occupational and physical therapists. Fine
motor and daily living skills were shaped using therapeutic principles. The two measures, PMAL and
TAUT, were reported earlier in the description of a case
study by these same authors.
The children who were casted improved signicantly
on the parent interview (rating both the amount of use
and quality of use) and also improved signicantly on
the TAUT. Follow-up evaluation (using the PMAL)
indicated that the gains were sustained over time. Taub
and colleagues (2004) concluded that the CI therapy
intervention produced large improvement in the use
of the more affected extremity. The children gained
9.3 new motor behaviors in a 3-week therapy period. A
critical therapeutic factor appears to be the concentrated extended nature of training conducted for many
hours daily over consecutive weeks. The authors discuss
the feasibility of concentrated doses of therapy. Because
6 hours of therapy each day is not reimbursed, not
practical for busy families, and not feasible for certain
446
CHILDREN WITH
DEVELOPMENTAL COORDINATION
DISORDER OR MILD DISABILITIES
Children with developmental coordination disorders
(DCDs) or dyspraxia form another group of children
who typically have delays in hand function and who
frequently receive OT services. Unlike children with
CP who have difculty with basic movements such as
grasp and release, children with DCD generally have
functional movement patterns but have difculty with
visual motor integration, bilateral coordination, rapid
alternating movements, sequences of movement, and
precise manipulation. This section describes efcacy
studies of children who have basic hand skills (i.e.,
reach, grasp, release) but demonstrate difculties integrating ne movements with sensory information to
perform the higher levels of visual motor skills, manipulation, and bilateral coordination (Table 19-3). In
children with DCD (this term encompasses dyspraxia
for purpose of this chapter), daily living skills, such as
fastening buttons and zippers, tying shoelaces, and
handwriting are difcult to learn, may require excessive
time to perform, or may be poorly performed. A variety
of approaches have been used with children who have
DCD including cognitive orientation to daily occupational performance, sensorimotor interventions, and
practice of functional activities. This section describes
efcacy studies of OT approaches to DCD in which
hand function outcomes are a primary focus. Sensory
integration practice models are not described here, as
reviews of sensory integration efcacy have been published elsewhere (Mulligan, 2003; Parham & Mailloux,
2005; Vargas & Camilli, 1999) and generally the aim of
sensory integration treatment is to enhance integration
of foundational perceptual-motor functions (e.g.,
motor planning, visual perception, bilateral integration,
and sequencing).
448
Table 19-3
Authors
Level of
Evidence
Sample
Intervention
Measures
Findings
Polatajko, Mandich,
Miller & Macnab
(2001)
Level IV
pre- and
postmeasures
with
intervention,
no control
N = 13,
children with
developmental
coordination
disorder
Children were
taught verbal
self-guidance and
to set goals
Functional
goals;
Developmental
Test of Visual
Motor
Integration
(VMI),
Test of Motor
Impairment
(TOMI)
Achieved 9 of 10
goals. VMI and
TOMI were not
statistically
different.
Miller, Polatajko,
Missiuna, Mandich,
& Macnab (2001)
Level I
randomized
clinical trial
N = 29,
developmental
coordination
disorder. Age
mean = 9 yrs
Cognitive
Orientation to
Daily Occupational
Performance
(CO-OP) for 10
sessions or
regular
OT approaches
(control) for 10
sessions.
COPM,
Performance
quality,
Vineland
Adaptive
Behavior Scales
(VABS),
BruininksOseretsky Test
of Motor
Prociency
(BOTMP),
Visual Motor
Integration
(VMI)
COPM improved
for both groups,
but more for the
CO-OP group.
CO-OP also
improved more in
performance
quality, and VABS
Motor. Both
groups improved
on the BOTMP
and VMI.
450
Table 19-4
Authors
Level of
Evidence
Sample
Intervention
Measures
Findings
DeGangi,
Wietlisbach,
Goodin, & Scheiner
(1993)
Level II
crossover
using a
sample of
convenience
N = 12,
developmental
delays, not
severe
disability; age
= 3671
months
Child-centered
therapy
emphasizing
interaction and
structured
sensorimotor
therapy for 8
weeks with
crossover
PDMS-FM
sensory
integrative
functioning,
behavior,
attention, play
Gain in ne motor
skills was higher
for child-centered
therapy; gain in
sensory integrative
skills was higher
for structured
sensorimotor
therapy; gross
motor skills
improved more
with structured
sensorimotor
therapy; no
denitive ndings
for behavior,
attention, and play
Case-Smith (2000)
Level IV
pre- and
postintervention
measures of
one group
N = 44, mild
delays; ages
= 46 years,
mean N = 57
mo
Occupational
therapy
emphasizing ne
motor function
In-hand
manipulation;
eyehand
coordination
Visual
perception
(DTVP);
PDMS-FM
visual motor
(DTVP);
function (PEDI)
Improvements in
all assessments;
interventions
using play and
social activities
were most
associated with
visual motor and
ne motor gains
Dankert, Davies,
& Gavin (2003)
Level II
quasiexperiment;
sample of
convenience
N = 43, 12
with disabilities
who received
OT, 16 typical
children in
OT, and 15
typical children;
age = 36 years;
mean = 53
months
Occupational
therapy for two
of three groups,
30 minutes of
one-on-one and
30 minutes of
group
intervention for
children with
delays
(VMI)
Visual
Perception
Motor
Coordination
Children with
delays who
received
occupational
therapy improved
in visual motor
integration and
visual perception,
but did not
improve in motor
coordination more
than children
without disabilities.
INTERVENTIONS TO IMPROVE
HANDWRITING
Handwriting is an important school and life function.
When handwriting is poor, the child may be penalized
with poor grades on school work and written assignments. When handwriting is illegible, school achievement and self-esteem can be negatively affected
(Graham, Harris, & Fink, 2000; Jones & Christensen,
1999). Individual differences in handwriting skills and
handwriting fluency predict how much and how well
children compose and express ideas in writing (Graham
et al., 2000; Jones & Christensen, 1999). The production of written text requires the coordination of
multiple skills. Visual motor integration appears to be
a fundamental prerequisite (Cornhill & Case-Smith,
1996; Tseng & Murray, 1994). Manipulation and
motor skills are also highly related to handwriting skills
(Cornhill & Case-Smith, 1996; Graham & Weintraub,
1996). Given its importance to childrens success in
school, a number of handwriting instructional approaches
and interventions have been developed (see Chapters
14 and 15). Handwriting interventions vary in their
theoretic model and the specic techniques and activities applied. In general, efcacy studies of handwriting
interventions have demonstrated signicant effects.
This section reviews the experimental studies that have
examined the effects of educational and therapeutic
interventions designed to improve handwriting skills
(Table 19-5).
I NSTRUCTIONAL APPROACHES
Instructional approaches often follow behavioral principles, providing structure for learning, instructing
children in practice of skills, and then providing feedback and reinforcement about the childs performance.
Generally, these approaches involve guided practice.
Learning principles are followed but instruction generally does not consider individual differences among
children. Berninger and co-workers (1997) implemented
a comprehensive study of handwriting interventions
based on different instructional methods. A randomized experimental design was used with a sample of
144 rst-grade children who were identied as being
at risk in handwriting. Five distinct instruction-based
interventions were implemented. The rst was motoric
imitation in which the teachers modeled motoric acts
but were nonverbal. In the second instructional
approach visual cues were provided using numbered
arrows to cue the sequence of strokes. The third
instructional approach involved memory retrieval; the
children were required to cover letters and write them
from memory. The fourth instructional approach
452
Table 19-5
Authors
Level of
Evidence
Sample
Intervention
Measures
Findings
Hayes (1982)
Level I
randomized
clinical trial
N = 45, in
kindergarten
and N = 45 in
third grade,
typical children
Five instructional
conditions:
copying with no
prompting, visual
demonstration
with copying,
visual and verbal
demonstration
with the child
verbalizing during
copying, control;
one single 25minute session
Letter form
reproduction
Level IV
ABC single
subject
N = 2, learning
disabilities;
ages = 10.6
and 11.4
Self-instruction
procedures.
Students used card
to guide their
handwriting and
to self-evaluate.
In the nal phase,
the students did
not use the card
but were
instructed to
self-cue.
Mean number
of words
written; quality
of handwriting
The students
wrote more and
the quality of their
handwriting
improved
Berninger, Abbott,
Vaughan, et al.
(1997)
Level I
randomized
experimental
design,
ve-group
comparison
Instructional
approaches: motor
imitation, visual
cuing, memory
retrieval, visual
cuing and
memory retrieval,
copying without
cuing, control
group; 24
20-minute
sessions were
provided
Handwriting
legibility,
automaticity,
dictation
accuracy,
writing fluency,
and nger
function
All intervention
resulted in
improvement in
measures except
automaticity.
Visual cuing with
memory retrieval
was the most
effective
intervention.
Jongmans,
Linthorst-Bakker,
Westenberg, &
Smits-Engelsman
(2003)
Level II
quasiexperimental
in which
controls
and
intervention
groups were
matched
N = 36
children in
special
education,
18 in each
group; mean
age = 9 yrs
Motor learning
principles are
taught; Selfinstruction and
self-reflection on
handwriting
Handwriting
quality
Handwriting
quality was
signicantly
higher in children
who received the
instructional
approach.
Table 19-5
Authors
Level of
Evidence
Sample
Intervention
Measures
Findings
Case-Smith (2002)
Level II
quasiexperimental
N = 38, 29
who received
occupational
therapy and 9
who did not;
all with poor
handwriting,
third, fourth,
and fth grades
Occupational
therapy, 9 hours
of direct services
over 9 months
Visual motor
control; visual
perception;
in-hand
manipulation;
Evaluation Tool
of Childrens
Handwriting
(ETCH)
Children who
received
intervention
improved more in
in-hand
manipulation,
visual motor
control, and letter
legibility. They did
not improve more
in handwriting
speed.
Level I
randomized
clinical trial
N = 59,
children with
economic
disadvantages;
second grade;
mean age =
7.1 yrs
Intervention
group received
occupational
therapy 2/wk for
10 wks. Control
group did not
receive treatment.
Minnesota
Handwriting
Test (MHT)
Children in
intervention
scored higher on
the MHT; specic
gains were in
spacing, alignment,
and correct size.
Speed did not
improve.
Sudsawad,
Trombly,
Henderson, &
Tickle-Degnen
(2002)
Level I
randomized
experimental
design with
three groups
N = 45
children with
kinesthetic
decits and
handwriting
difculties, rst
grade; 15 in
each of the
three groups
One group
received
kinesthetic
training; one
received
handwriting
practice; one
received no
treatment.
Treatment was
30 min/day for
6 days.
Kinesthetic
acuity;
kinesthetic
perception and
memory; the
ETCH
Scores on the
ETCH did not
change. Kinesthetic
perception
improved for all
groups, but was
not signicantly
more improved in
any one group.
The teachers
reported
signicant changes
in handwriting for
all three groups.
sessions held twice a week. Measures included handwriting legibility, handwriting automaticity, dictation
accuracy, writing fluency, and nger function. The
interventions produced signicant improvement in all
handwriting assessments except the automaticity tasks
and quality of one writing task. Visual cuing with
memory retrieval was the most effective intervention
across measures. Composition fluency improved in
addition to handwriting legibility and improvements in
handwriting skills appeared to have a positive effect on
childrens ability to compose written text.
454
456
SUMMARY
Research evidence about treatment effects helps practitioners make good clinical decisions, provides practitioners with explicit information to give to families, and
helps practitioners justify treatment decisions to physicians and other professionals. When levels of research
evidence are high and rigorous methods are used,
therapists can generalize the ndings to their practice
with condence. When levels of research evidence are
low, ndings should be reported and applied with
caution because of inherent limitations. The majority of
studies on hand intervention effectiveness are Levels III
and IV and use small convenience samples. These
single-subject and case studies provide detailed information about treatment outcomes for individuals, but
cannot be generalized beyond the characteristics of the
children who participated. Although case studies and
single subject design studies deepen understanding
of intervention effects, they do not provide denitive
information from which predictions about outcomes
can be made. In the past decade more rigorous (Level
I) randomized clinical trials have been completed,
providing more denitive ndings and making important contributions to the knowledge base for hand
function intervention outcomes.
The studies reviewed in this chapter examined various levels of function and disability. Many hand intervention studies have examined impairment level (body
structure and body function) outcomes. For example,
the studies of upper extremity weight bearing examined
ROM, muscle tone, and movement patterns (i.e.,
components of performance). Studies of casting also
emphasized ROM and muscle tone. Even studies of
comprehensive interventions (e.g., neurodevelopmental treatment) often used measures of arm and
hand movement rather than functional or occupational
measures. Impairment-level outcome measures leave
unanswered questions about if and how performance
and function changed given intervention effects.
Measures of function and occupation, in addition to
performance of specic skills, help to link interventions
to childrens daily lives and social roles. Researchers
(Butler & Darrah, 2001; Law & Baum, 2001) have
suggested that outcome studies routinely couple specic performance measures with holistic, comprehensive assessment of function and occupation. Examples
of holistic assessments to be included are those that
measure functional goals (e.g., the Canadian Occupational Performance Measure), self-care and mobility
function (e.g., Pediatric Evaluation of Disability
Inventory), adaptive behavior (e.g., the Vineland
Adaptive Behavior Scales), or use of hands in play (e.g.,
the Toddler Arm Use Test). Measures of play skills,
playfulness, or quality of life also should be used in
association of measures of sensorimotor skill.
Specic studies reviewed in this chapter did use
functional and occupational assessments. For example,
Miller and co-workers (2001) study of cognitive orientation to daily occupational performance implemented
the Canadian Occupational Performance measures,
the Vineland Adaptive Behavior Scale, the BruininksOseretsky Test of Motor Prociency, and the Visual
Motor Integration test. These assessments examined
broad aspects of function and the childs integration of
sensorimotor-perceptual-cognitive skills. The ndings
that resulted answered questions about the childrens
occupations after intervention. Other studies that
examined the effects of holistic interventions (e.g.,
preschool OT services [Case-Smith, 2002]) demonstrated the associations between childrens performance of basic skills and their functional outcomes.
Future hand intervention research should examine
childrens play and school outcomes to determine
effects on everyday life and childrens roles as students,
play partners, and family members.
Another limitation in interpreting the research literature is that the independent variable, the hand function intervention, is rarely described in detail in the
research report. As a result, it is not clear exactly what
intervention strategies were used and to what interventions the study results apply. In order to assure that
the intervention is true to its theoretic model and is
reliably applied across researchers and time, measures
of treatment delity are needed. Almost none of the
studies used checks on treatment delity; consequently,
the external validity of ndings can be questioned, as
treatment protocols are easily and unintentionally altered
during implementation. Certain interventions (e.g.,
neurodevelopmental treatment) have been dened
differently over time (Howle, 2002); therefore, explicit
information about what intervention activities and
strategies were administered is provided in the research
report. Publications of standard or best practice intervention models can be used to dene interventions in
clinical trials.
A nal limitation observed in many of the studies
was lack of long-term follow-up. Often studies implemented a post-assessment immediately after intervention, and did not follow childrens progress to
determine the long-term effects of intervention.
Outcomes of childrens occupations and roles as they
enter adolescence and adulthood have rarely been
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Glossary
461
462 Glossary
Dynamic tripod grasp (pencil): Grasp in which the
pencil is stabilized against the side of the middle
nger by the pads of the thumb and index nger.
Writing includes localized movements of the ngers
and thumb as well as the wrist.
Glossary 463
Motor learning: A set of processes associated with
practice or experience leading to relatively permanent
changes in the capability for producing skilled
action.
Movement unit: Constituted by one phase of
acceleration of a limb followed by a deceleration. A
movement can consist of one or more movement
units.
Multimodal exploration: The simultaneous use of
more than one sensory system in object exploration.
Occupation performance: Performance of skills that
are essential for independent functioning in everyday
living.
Palmar grasp: A whole-hand grasp in which objects
are held against the palm of the hand by the ngers.
The thumb may be active or passive.
Palmar grasp (pencil): A grasp in which the pencil
is positioned across the palm and held in a sted grip.
Pathologic handedness: Altered handedness
resulting from neural insult.
Perception: A process of collecting information from
the environment based on vision, touch, hearing, and
proprioception in order to construct an internal
representation of the environment and body.
Perceptual activity of the hand: Use of the hand as
a perceptual system, in which motor activity is
primarily exploratory and information seeking.
Perceptual-motor processes: The reciprocal
relationship between perception and action, wherein
movement adapts to perception and movement
influences perception.
Pincer grasp; pinch; fine prehension: The grasp of
an object with the index nger and thumb. Major
types include palmar pinch (pad of nger to pad of
thumb), tip pinch (using tips of both thumb and
nger), and lateral pinch (thumb holding object
against side of nger).
Postural control: The maintenance of body position
in space that evolves from the development of
antigravity movement, postural adjustment reactions,
and somatosensory input.
Power grip: A static grip applying force to an object
to immobilize it in the hand.
Praxis: The planning and execution of a motor
movement or a series of motor movements/tasks.
Precision grip: The grasp of an object with the
nger and thumb pads or tips. Precision grips may be
static but often allow movement of the object by or
within the ngers.
Precision handling: The dynamic or manipulative
characteristics of precision grip used for in-hand
manipulation and for the use of many tools.
Prehension: The voluntary act of grasping and
manipulating objects with the hand.
464 Glossary
Shift: An in-hand manipulation movement where
there is slight adjustment of an object on or by the
nger pads.
Somatosensory: Refers to the tactile and
proprioceptive senses that contribute to the
perception of objects and events, as well as of the
body and limbs.
Spasticity: Velocity-dependent resistance to passive
movement.
Squeeze grasp: An immature grip in which an infant
presses an object against the palm with total nger
flexion. The thumb does not participate and force is
not modulated.
Stabilizing: Contraction of the muscles to xate or
hold the body or a body part; also refers to the use of
external systems or devices to provide support when
an individual is unable to do so alone.
Static splint: An immobilization or supportive splint
that has no moving parts; serial static splints are
periodically remodeled as the joint gains motion;
static progressive splints use low load in a single
direction over a long period of time to mobilize soft
tissue at its end range.
Static tripod grasp (pencil): Grasp in which the
pencil is stabilized against the side of the middle
nger and held by the pads of the index nger and
thumb. The hand is moved as a unit by the wrist and
forearm in writing.
Stereognosis: The recognition of familiar objects
through touch.
Stiffness: A general term referring to difculty
moving the limbs.
Switched handedness: Occurs when an inherently
left-handed child learns to draw and write with the
right hand because of sociocultural influences.
Tapping: A facilitation technique that is manually
applied and used to generate volitional movement at
individual muscles.
Three-jaw chuck: A power grip of the ngertips.
The object is held with the distal pads of the thumb,
index, and middle ngers.
Threshold tests: Tests that determine the minimal
stimulus a person can perceive (e.g., pain,
temperature, pressure).
INDEX
A
Abductor pollicis muscles, 31-34, 33f, 35f
Acceleration
illustration of rates of, 56f
Accordion tube toys, 271
Active range of motion (AROM), 370, 371f, 373
Activities of daily living (ADLs)
for burn victims, 393
evaluation of
following hand wounds, 376, 377t-379t
handedness issues with, 183-184
and self-care, 193-214
Adaptations
for hand skill problems, 240-241
reaching
and motor impairments, 96-97
Adapted tripod grip, 331f, 461
Adductor pollicis muscles, 34-35
Adults
drawing skills in, 220
haptic manipulation strategies in, 70-71
reaching movements by, 94-95
role of vision and cognition
in haptic perception, 74-76
Afferent feedback, 47-48, 218
Affordances, 461
Alpha motor neurons
of hand muscles
direct corticospinal connections to, 4-5
Ambidextrous
denition of, 166b
Anatomy
of the hand, 21-43
Anterior intraparietal sulcus
importance in movement, 16
Anticipatory control
development of, 52-53
during infancy, 94
in developmentally disabled children, 56-57
glossary denition of, 461
and learning, 47
Anticipatory postural control, 346
Anticipatory scaling, 57
465
466 Index
Bilateral hold
cooperative
denition of, 461
Bilateral integration and sequencing (BIS)
dysfunction, 326-327
Bilateral skills
difculties
interventions for, 260-262
of manipulation, 256
needed for hygiene and grooming, 210, 211t, 212t
sample short-term goals for, 244, 245b
and self-care, 213
transitional, 131-134
Bimanual skills
from birth to 12 months, 131-134
coordination of, 134
developmental sequence of
birth through 24 months, 138t-139t
and hand preference, 164
Blocked range of motion (BROM), 370, 371f, 373
Blocking gloves, 387f
Bobath approach, 343, 344-347
Body charts
to identify pain, 376
Bones
anatomical diagram of hand, 22f
embryonic development of, 21-22
Botulinum toxin (BOTOX), 447
Boutonniere deformities
splinting, 418f
Brachial plexus injuries, 418
Brain injuries
and haptic perception problems, 81
Bristle blocks, 272, 277
Brodmanns areas, 8-9, 10f
Bruininks-Oseretsky Test, 231, 449
Buddy taping, 417
Burns
in children
classication of severity, 392-394, 390t
closed wound scarring phase of, 392-394
open wound phase of, 390-392
patterns of, 389-390
management of scars, 391-393
Buttoning, 154, 208, 209t, 210, 273, 275-276, 276-277
C
Callosal dysfunction, 176
Capacity
denition of, 104
Capitate
anatomical diagram of, 22f
description and position of, 22-23
ligaments of, 23, 24f
Carpal bones
diagram illustrating, 22f
embryonic development of, 21-22
Carpometacarpal joints
anatomy of, 23, 24, 25f
and handwriting, 322
Carpus, 23, 24f, 25f
Case studies
on cognition and motor skills, 101-102
concerning cerebral palsy
and neurodevelopmental treatment (NDT), 355-359
Index 467
Children (Continued)
haptic perception development in, 65-67
illustration of hand ability in, 46f
interventions
for hand skill problems, 239-264
with motor impairments
reaching/coordination problems in, 96-97
object manipulation development in, 154-158
prehensile force control development in, 45-46
preschoolers
ne motor program for, 267-287, 289-291
role of vision and cognition
in haptic perception, 74-76
using sensory information
for reaching, 95
Childrens Handwriting Evaluation Scale (CHES), 302t-305t,
314-315
Chinese speed test, 304t-305t
Chunking, 106, 108
Clot formation, 368-369, 370b
Clumsiness
causes of
in children, 54-58
Cock-up splints, 381f
Cognition
denition of, 461
development of, 45, 110
factors in self-care, 214
and hand ability in children, 46f
importance of
for motor skill acquisition, 102-103
and motor skills
adaptation, 102
attention and perception, 104-105
case scenario, 101-102
concept formation, 106-107
importance in acquisition of, 102-103
memory, 107-108
perceptual-motor processes, 105-106
processes of, 103-108
problems
with cerebral palsy, 344
role in haptic perception, 74-76, 77
Cognitive neuroscience approach
to cognition and motor skill development, 103
Cognitive Orientation to Daily Occupational Performance
(CO-OP), 447-449
Cognitive skills; See cognition
Coincidence anticipation, 461
Collagen, 368-369, 370b
Collateral ligaments
accessory, 25, 26f
cord portion of, 25, 26f
splinting of, 383-384
Columnar carpus, 23, 25f
Communication
using hands, 101
writing, 291
Complementary two-hand use, 152-153,
158
Composite flexion, 461
Computers
and drawing, 224-225
and handwriting, 232
Concept formation
denition of, 461
description of, 106-107
468 Index
Digital interphalangeal joints, 26f, 27
Digital pronate grasp, 281f
Digits
anatomical diagram of, 22f
description and position of, 22-23
embryonic development of, 21-22
fractures and dislocations of, 383-384
ligaments of, 23, 24f, 25, 26f
muscles and tendons of, 33-34, 36f
Disabilities
affecting drawing abilities, 225
and keyboarding, 232
Disk grip, 461
Dissociation, 461
Distal nger control
practice sheet for, 339f
Distal grips, 335b
Distal phalanges
anatomical diagram of, 22f
description and position of, 22-23
ligaments of, 23, 24f
Distal transverse arch
anatomical diagram of, 23f
description of, 22
Diversity; See culture
Dorsal interossei muscles, 32-34, 35f
Dorsal stream, 104-105, 461
Down syndrome
affecting drawing abilities, 225
affecting grip force, 11
and haptic perception, 80-81
reaching skills affected by, 96
Drawing; See also graphomotor skills
and computers, 224-225
denition of, 217
development in preschoolers, 280-284
and developmental evaluation, 225-226
instruction and practice, 229-232
motor learning theories, 218
nature of, 220-221, 222f, 223-224
and pencil grasp, 282-283
phases of, 221, 222f
role of vision and kinesthesis in, 218-219
tools, 280-281
Dressing skills
antecedents of, 203, 205t
with fasteners, 208, 209t, 210
learning
and hand skill development, 203, 205t, 206, 207t, 208,
209t, 210
order of difculty, 208b
undressing, 206t
without fasteners, 206, 207t
Drinking, 199, 200t
Dual motor systems, 461
Dynamic grasp, 280-281
Dynamic muscle tone, 461
Dynamic splinting, 408, 461
Dynamic tone, 461
Dynamic tripod grip, 210-220, 462
Dyspraxia
and haptic perception, 81-82
E
Earedness, 181
Eating, 199, 200t, 201, 202t, 203, 204t
Ecological approach
to cognition and motor skill development, 103
Edema
description of, 375
management of burn, 391-392
sandwich splints for, 391f
Edinburgh Handedness Inventory (EHI)
description of, 170-171
reliability of, 170t
Elbows
casting and splinting, 380f, 381f
embryonic development of, 21-22
Encoding phase
of explicit memory, 108
End range of movement, 462
Episodic memory, 107-108
Epithelization, 368-369, 370b
Ergonomics
affecting handwriting, 298t, 301, 306
Ethnicity; See culture
Evaluation Tool of Childrens Handwriting (ETCH), 302t303t, 316-317
Evaluations
of hand injuries
activities of daily living, 376
hand dexterity, 374-375
hand sensibilities, 376
hand strength, 373-374
interview and history, 370
pain, 375-376
range of motion, 370-375
wound, edema and scarring, 375
of handwriting
actual performance, 300-301, 302t-305t, 306
ne motor skill, 296-297
gross motor skill, 295-296
keyboarding performance, 306-307
motor performance, 294-295
neuromuscular and neurodevelopmental status, 293
pre-evaluation data collection, 292
related performance components, 292-300
visual motor control, 297-298
visual perception components, 293-294
of haptic perception
in infants and children, 77-78
Executive function
of the hand, 462
Explicit memory, 107, 462
Exploration
and haptic perception, 69-74
by infants, 73b
movements used in object, 144-147
and object dimensions, 71t
Extensor lag, 462
Extensor pollicis muscles
of hand, 31-35, 32f
Extensor tendons
injuries to, 388-389
Extrinsic muscles
and tendons
of hands, 27, 28f-29f, 29-31, 32f
Eyedness, 181
Eye-hand coordination
denition of, 462
interventions to improve, 242-243
play activities to improve, 273-275
and reaching, 89-97
Index 469
F
Face pain scale-revised (FPS-R)
to measure pain, 376
Facilitation
case study techniques of, 352, 357t, 362t
denition of, 350
techniques of, 350-351
Fasteners, 208, 209t, 210
Feedback, 462
Feed-forward controlled movements, 47
Feeding; See self-feeding
Fibroblastic stage
of wound healing, 369
Fine motor coordination, 462
Fine motor skills
activities that help children learn, 285b
case study on preschoolers, 285-286
emphasis on
in different cultures, 121-122
evaluating handwriting, 296-297, 298t
goals for preschoolers, 267-268
and handwriting instruction, 230-231
instruments to assess, 296t
learning on vertical surfaces, 268-269
planning, 278
problems in children, 239-262
and visual perceptual inventory
for preschoolers, 290-291
Finger feeding, 199, 200t
Finger plays, 289
Fingers; See also digits; phalanges
biomechanics of flexor pulley system, 38f
embryonic development of, 21-22
force coordination in, 55-56
fractures and dislocations of, 383-384
and in-hand manipulation skills, 255-260
isolation activities, 275
movements of, 4-5
in older children, 157-158
sensory function, 7-9
and tactile system, 48-54
and vision
and object manipulation, 147-148, 149f
Fisted hands
problems with, 250
splinting for, 406t
Fixing, 462
Flexor pollicis muscles, 31-34, 33f, 35f
Flexor tendons
injuries to, 385-388
splinting, 417-418
Food; See also self-feeding
and learning to self-feed, 199, 200t, 201, 202t, 203, 204t
serving and preparing, 203, 204t
Footedness, 181
Force coordination
in grasping and lifting, 55-56
Forearms
embryonic development of, 21-22
muscles of, 31f
nerves associated with tendons and muscles of, 28f-29f, 31f,
32f, 33f, 37-40
power of muscles in, 37, 38t
Fractionate, 4, 16
Fractures
of ngers, 383-384
splinting for, 417
of wrist, 380-383
Friction
of objects
and anticipatory control, 53
Friedrich and Baumel casts, 388f
Full arm casts, 380f
Functional range of motion, 370-371, 372f, 375
G
Gamekeepers thumb, 383-384
Gender
and haptic perception, 67
and self-care skills, 197
Geoboards, 272, 275
Gestation, 21-22
Glossary, 461-464
Graphesthesia test (GRA), 78
Graphomotor skills; See also drawing; handwriting
acquisition of, 217-220
motor learning, 218
denition of, 217, 462
development of, 217-233
drawing, 220-226
grasping and manipulating tools, 219-220
handwriting, 226-232
role of vision and kinesthesis in, 218-219
ergonomic factors, 298t, 301, 306, 320
writing implements, 220
Grasp; See also grip
and anticipatory control, 53
basic coordination of forces during, 48-51
case scenario concerning, 101-102
developmental sequence of
birth through 24 months, 138t-139t
experiments involving, 48-51
illustration of normal, 42f
importance of postural control in, 346
by infants
systems that influence, 122-126
interventions
for problems with, 249-251
mass, 5
and object manipulation
in infants and children, 143-158
and osseous arches, 23
power
functional patterns of, 41-43
precision, 41-43
preparation and vision, 11-13, 16
in preschoolers
for drawing/ writing, 280-281
primitive and transitional, 127-128
purposeful, 128-130
radial nger patterns, 251-253
role of somatosensory cortex in, 10-11
sample short-term goals for, 244, 245b
of scissors, 279
and self-dressing, 205t
and sensorimotor control, 53-54
and sensory feedback, 16
strength and Strong Hands, 273, 274b
470 Index
Grasp (Continued)
and tripod grips, 219-220
variability in, 155-157
Grasp phase
denition of, 462
of reaching, 90-91
Grip; See also grasp
affecting handwriting, 298t, 301, 306
assessment systems, 297
in children with cerebral palsy, 11
denition of, 462
force development, 51
interventions for problems with, 249-251
power
description of, 41
functional patterns of, 41-43
precision
functional patterns of, 41-43
precision versus power, 4-5
and preshaping hand, 12-14
role of somatosensory cortex in, 10-11
tripod, 219-220
Grip force
coordination of, 55-56
denition of, 462
development of, 51
and friction, 53
illustration of, 50f
illustration of rates of, 56f
Grooming
developing self-care skills in, 210, 211t, 212t
Gross motor skills
emphasis on
in different cultures, 121-122
evaluation of
for handwriting analysis, 295-296
Grouping, 106, 108
H
Hamate
anatomical diagram of, 22f
description and position of, 22-23
ligaments of, 23, 24f
Hammering, 42f, 171b, 172
Hand muscles; See also muscles
direct corticospinal connections
to alpha motor neurons, 4-5
and the primary motor cortex, 5
Hand performance
denition of, 162
versus hand preference, 162, 163f, 164-165
skill and ability tests for, 171-172
Hand preference; See also handedness
denition of, 162, 462
four components of, 164
versus hand performance, 162, 163f, 164-165
linked to immature grips, 220
in preschoolers, 281-282
tests for, 170-171
Hand skills
complementary two-hand use, 152-153
development of
importance of posture and senses in, 122-126
and infant play, 117-137, 138t-139t
Index 471
Hands
anatomy and kinesiology of, 22-43
clumsiness or impaired function of
in children, 54-58
diagram illustrating bones of, 22f
embryonic development of, 21-22
extrinsic muscles
and tendons of, 27, 28f-29f, 29-31, 32f
functional patterns of, 41-43
isolated movements of, 247-249
joints and ligaments of, 23-27
movements of
sensory function, 7-9
summary and therapeutic implications, 16
muscles and tendons of, 27, 28f-29f, 29-37
nerves associated with, 28f-29f, 31f, 32f, 33f, 37-40
osseous structures of, 22-23
perceptual functions of, 63-83 (See also haptic perception)
power of muscles in, 37, 38t
preference (See handedness)
preshaping of, 12-14, 16
role of inferior parietal lobe in, 12-13
research studies
on effects of cerebral palsy, 436t-440t
sensation and anticipatory control in, 346-349
sensibility of, 376
skin and subcutaneous fascia, 40, 41f
systems that contribute to abilities of, 46f
Handwriting
consequences of bad, 291
denition of, 217, 462
development in preschoolers, 280-284
developmental progression of, 226-229
diagram illustrating skilled, 218f
ergonomic factors, 298t, 301
evaluation of
actual performance, 300-301, 302t-305t, 306
ne motor skill, 296-297
gross motor skill, 295-296
keyboarding performance, 306-307
motor performance, 294-295
neuromuscular and neurodevelopmental status, 293
pre-evaluation data collection, 292
related performance components, 292-300
visual motor control, 297-298
visual perception components, 293-294
handedness actions involved in, 182-183
implement grasp and manipulation, 219-220
instruction and practice, 229-232
interventions to improve
efcacy studies on, 451, 452t-453t, 454-456
kinesthetic approach to teaching, 335-340
learning on vertical surfaces, 268-269
legibility of, 226-228, 300-301
tests for assessing, 302t-305t, 311-318
manipulatives program before learning, 270-278
motor learning theories, 218
performance factors, 229-232
prosthetic devices, 331, 332f
quality of, 227-228
reported mean speed, 228t
role of vision and kinesthesis in, 218-219
and skilled tool use, 14-16
speed of, 226-228, 301
tests for assessing, 302t-305t, 311-318
teaching principles and practices, 319-342
Handwriting (Continued)
bilateral integration, 326-327
kenesthetic approach to, 335-341
kinesthesia, 328-330
pencil grip, 330-331, 332f, 333-335
spatial analysis, 327-328
training groups, 319
upper extremity support, 320-321
visual control, 324-325
wrist and hand development, 321-324
tests for assessing, 302t-305t, 311-318
versus writing, 226
writing tools, 220
Handwriting Speed Test, 304t-305t, 317-318
Haptic perception
accuracy, 67
denition of, 63-64, 462
development in children, 65-67
development in infants, 64-65
disorders of, 79-80
evaluation of
in infants and children, 77-78
functions contributing to, 68-77
manual manipulation and exploration
in adults, 70-71
in children, 73-74
in infants, 71-73
strategies, 69-74
and recognizing objects and shapes, 65-67
role of somatosensory sensation in, 69
summary and implications for practice, 67-68, 82
of texture, size and weight, 66
visual, 65-66
Healing
phases of wound, 368-369, 370b
Hemiplegic cerebral palsy
coupled movements with, 97
High load brief stress (HLBS), 419
Holding skills
bilateral, 133
Hygiene
developing self-care skills in, 210, 211t, 212t
Hypertonia
versus hypotonia, 349
Hypotonia
versus hypertonia, 349
I
Ilizarov, 396
Imaginary play, 125
Implicit memory, 107, 462
Independence
in self-care skills
cultural and social factors, 196-197
and disabilities, 194-195
importance to children, 194
maturation and motivation, 197-198
motor factors, 198
sex difference, 197
Independent activities of daily living (IADLs)
and self-care, 193-214
Index nger
embryonic development of, 21-22
grip force rates, 56f
splints, 416f
472 Index
Index grip, 333, 334f
Infants
bimanual skills in, 131-134
contexts of learning, 121-122
development of reaching skills, 92-95
hand skill development in
contexts for, 121-122
in play context, 117-137, 127-137, 138t-139t
systems that contribute to, 122-127
theories of, 117-121
haptic manipulation strategies in, 71-73, 76-77
haptic perception development in, 64-65
learning skills in, 108-110
measuring pain in, 375-376
neonatal
splints, 415-417
object manipulation
stages of, 143, 144-150, 144b
object release in, 130-131, 136-137
play activities
12-24 months, 134-136
birth to 12 months, 127-129
and posture, 122-124
preterm
haptic perception disorders in, 79-80
reaching movements by, 94-95
role of vision and cognition
in haptic perception, 74-76
sensory progression in, 124-126
Inferior parietal cortex
and tool use, 14-16
use-dependent organization of, 14
Inferior parietal lobes
diagram illustrating, 13f
functions of
and hand movements, 12-13
role in preshaping of hand, 12-13
Inferior pincer grasp, 462
Inflammation
clinical signs and implications of, 368-369
stage of, 368
In-hand manipulation
assessment of, 297
denition of, 150, 462
ve basic types of, 255b
general principles for developing, 256-260
important factors influencing, 156-157
intervention strategies, 255-260
sample short-term goals for, 244, 245b
sequence of difculty, 256-257
and Smart Hands activities, 273
studies of, 154-155
Inhibition
case study techniques of, 352, 357t, 362t
denition of, 349
techniques of, 350
Intermodal perception, 462
Interpretive phase
of drawing, 221, 222f
Interventions
for cerebral palsy
neurodevelopmental treatment (NDT), 353-354
to enhance hand function
efcacy of, 433-457
grasp levels, 251-253
for hand skill problems in children
Interventions (Continued)
goal setting, 243-244, 245b
impact on occupational performance, 239-240
intervention approaches, 240-241
intervention planning factors, 241-243
intervention strategies, 244-262
research, 244
splints, casts and constraints, 262-263
for handedness, 180-184
to improve handwriting
efcacy studies on, 451, 452t-453t, 454
muscle tone and posture, 247
positioning, 246
surgical and medical, 446-447
typical problem areas, 245b
Intraparietal sulcus
diagram illustrating, 13f
Intrathecal baclofen, 446-447
Intrinsic hand muscles
and alpha motor neurons, 4-5
and tendons, 31-35
J
Joint capsules, 25, 26f
Joints
deep pressure, 351
embryonic development of, 21-22
metacarpophalangeal, 23, 25, 26-28
of phalanges, 23, 24f, 25, 26f
stability and mobility
and hand function, 277
Juvenile arthritis
splinting, 418
K
Key points of control
with cerebral palsy, 350
in neurodevelopmental treatment (NDT), 349, 353-354
Keyboarding, 232, 306-307
Kinesiology
of the hand, 21-43
Kinesthesia
denition of, 219, 462
and proprioception, 48
role in graphomotor skills, 218-219
and teaching handwriting, 230-231, 328-330, 329b,
335-340
Kinesthetic Sensitivity Test (KST), 219, 231
Kinesthetic teaching techniques, 335-340
Kleinert splints, 385, 386f
Knickerbockers test, 171b, 172
Knowledge
components of, 106-107
and memory, 107
L
Lacing activities, 273-275
Language disorders
and haptic perception, 81-82
Lateral tripod grasp, 462
Learned movements
description of, 47
Learned non-use, 462
Index 473
Learning
denition of process of, 102, 108-110
descriptions of, 109b
dressing skills, 203, 205t, 206, 207t, 208, 209t, 210
and sensorimotor control, 53-54
stages of
in infants, 120-121
to write name, 283b
Learning disabilities
and haptic perception, 81-82
Left handedness
consistent versus inconsistent, 168
denition of, 166b
intervention theories for, 182-184
Letters
presenting models for, 339-340
Lifting
and anticipatory control, 53
coordination of forces during, 48-51
performed at different ages, 50f
Ligaments
checkrein, 27
collateral, 25, 26f
of digital joints, 25, 26f
splinting, 383
of wrist, 23, 24f
Limb position sense
and proprioception, 48
Load force
illustration of, 50f
illustration of rates of, 56f
Loading phase
and manipulation force development, 51
Longitudinal arch
anatomical diagram of, 23f
description of, 22
Low load prolonged stress (LLPS), 419
Lunate
anatomical diagram of, 22f
description and position of, 22-23
ligaments of, 23, 24f
M
Mallet nger, 384
Manipulation; See also in-hand manipulation; object
manipulation
and anticipatory control, 52-53
bilateral, 260-262
complexity of, 101
denition of, 144, 147
examples of strategies of
by children, 74b
force development, 51
general principles for developing in-hand, 256-260
grip and nger
and self-care, 213
important aspects of, 102
by infants
systems that influence, 122-126
in-hand
intervention strategies, 255-260
versus prehension, 150
during preschool training, 270-278
role of in haptic perception in, 69-70
and sensorimotor control, 53-54
Manipulation (Continued)
Strong Hands and Smart Hands, 272-278
and tripod grips, 219-220
Manual Form Perception (MFP) test, 77-78
Manuscript writing
versus cursive, 324-326
kinesthetic approach to teaching, 335-336
Mastery motivation, 197-198
Mastication, 47
Matin Vigorimeter, 289
Maturation stage
of wound healing, 369
Mechanoreceptors
and touch, 48
Meissner corpuscles, 48
Memory
denition of, 107, 462
storing information in, 102
working
and handwriting performance, 229
Mental retardation; See also Down syndrome
and haptic perception, 80-81
Metacarpals
anatomical diagram of, 22f
description and position of, 22-23
embryonic development of, 21-22
ligaments of, 23, 24f
Metacarpophalangeal joints, 23, 25, 26-28
collateral ligaments of, 25f, 26
Middle phalanges
anatomical diagram of, 22f
description and position of, 22-23
ligaments of, 23, 24f
Miller Assessment for Preschoolers, 77
Minnesota Handwriting Assessment (MHA), 302t-303t, 306,
311-312
Mirror movements, 462
Mixed handers
denition of, 166b
Mobility
versus stability, 241
Motivation
and hand ability in children, 46f
to improve hand skills, 45-46
and interests
of children to learn, 242-243
mastery, 197-198
Motor control
summary of, 58-59
Motor impairments
affecting drawing abilities, 225
affecting reaching skills, 96
Motor learning
denition of, 347, 463
development of
in infant play context, 117-137, 138t-139t
and kinesthetic teaching techniques, 335-340
role of somatosensory cortex in, 11-12
theory of, 242
Motor programs
denition of, 47
Motor skills
affected by brain injuries, 81
and cognition
adaptation, 102
attention and perception, 104-105
474 Index
Motor skills (Continued)
case scenario, 101-102
concept formation, 106-107
importance in acquisition of, 102-103
memory, 107-108
perceptual-motor processes, 105-106
processes of, 103-108
denition of, 102
development of
versus cognitive skill development, 110
in infant play context, 117-137, 138t-139t
role of somatosensory cortex in, 11-12
variability in, 155-157
and evaluating handwriting, 294-295
goal setting interventions, 243-244, 245b
important aspects of, 102
and kinesthetic teaching techniques, 335-340
repetition and practice, 242
and self-care, 193-214
Mouth
two hands and exploration with, 145f
used for object exploration, 146, 147-149
Movements
acceleration and deceleration phases of, 93-95
and anticipatory control, 53
components of, 102
constraint-induced (CI) therapy
description of, 263
research and case studies on, 444-446
control theories, 46-47
development of
in small children, 51
disorders of
cerebral palsy, 344
goal directed, 102
in infants
and hand skill development, 117-121
isolated hand and arm, 247-249
learned
description of, 47
mature reaching
integration of sensory information, 92
role of proprioception, 91-92
role of vision in, 91
speed, 89-90
transport and grasp phase, 90-91
reaching
beginning stage, 92-93
coordinating body parts, 93
development during infancy, 92-95
planning, 93-95
sensory information, 95
variations, 95
summary of object manipulation, 148-149
theories of, 102-103
units, 463
used in object exploration, 144-146
Multimodal exploration
denition of, 64, 463
Muscle tone
assessment of
in cerebral palsy patients, 352
denition of, 349
neurodevelopmental approach to, 347
case study, 360-363
Muscles
balance and biomechanical considerations, 35, 37
embryonic development of, 21-22
extrinsic
of hands and arms, 27, 28f-29f, 29-31, 32f
and hand ability in children, 46f
intrinsic
of hands, 31-35
and proprioception, 48
tendon movement with, 37
weakness
with cerebral palsy, 344
work capacity of, 37, 38t
Myelomeningocele (MMC)
affecting drawing abilities, 225
affecting reaching movements, 96
N
Needle threading, 323, 324f
Neonatal infants
haptic perception disorders in, 79-80
splints, 415-417
Neoprene thumb abduction splints, 334f, 335
Neovascularization, 368-369, 370b
Nerves
associated with tendons and muscles
of hand, wrist and forearm, 28f-29f, 31f, 32f, 33f
injuries to
splinting approach, 418, 423-425
supply of
to forearm, hand, and wrist, 37-40
Neurodevelopmental Treatment Association (NDTA), 344-347
Neurodevelopmental treatment (NDT)
for cerebral palsy, 343-363
case studies, 355-359, 360-363
efcacy of, 354-355
research studies on, 440-443
facilitation techniques, 350-351
inhibition, 349-350
intervention process
for cerebral palsy, 353
key points of control, 349, 353-354
planning treatment, 352, 357t, 361t
and postural control, 347-346
role of sensation and anticipatory control in, 346-349
Neuromaturation model
of motor development, 117-118
Newborns; See infants
Newton Early Childhood Program, 267, 280, 283, 285-286,
289, 290-291
Nine-Hole Peg test, 297
Non-language learning disabilities (NLD), 327-328
Numeric rating scale (NRS)
to measure pain, 376
O
Object manipulation; See also manipulation
and anticipatory control, 346-349
and haptic perception, 69-74
in infants and children, 143-158
of multiple objects, 148
in older children, 157-158
in preschool and early childhood years, 154-157
Index 475
Object manipulation (Continued)
role of vision in infant, 147-148
during toddler years, 150-154
summary of, 153-156
Object release
from 12 to 24 months, 136-137
from birth to 12 months, 130-131
control of
by toddlers, 152
developmental sequence of
birth through 24 months, 138t-139t
Objects
characteristics of
and grasp interventions, 250-251
familiar versus unfamiliar, 56-57
and hand interaction
cortical control of, 3-17
handling of multiple, 148
infant exploration actions, 73b
in-hand manipulation of, 256-260
manipulation (See also object manipulation)
and exploration, 144-147
and haptic perception, 69-74
in infants and children, 143-158
release of (See also object release)
in infants, 130-131, 136-137
spatial orientation of, 67
substance, structure and function of, 71t
transporting, 251
weight, size and friction of
and anticipatory control, 52-53
Observation of Visual Motor Orientation and Efciency, 325
Occupational therapy
approaches to handwriting
efcacy research on, 454-456
approaches with preschoolers
research studies, 449-450, 451t, 453-454
cerebral palsy research, 436t-440t
effective sessions for preschoolers, 284-285
ne motor program for preschoolers, 267-287, 289-291
goal setting, 243-244, 245b
interventions
to enhance hand function, 433-457
for hand skill problems, 239-264
pediatric
and handedness, 179-184
role of performance
when treating cerebral palsy, 347
Opponens pollicis muscles, 31-34, 33f, 35f
Osseous arches
of the hands, 22, 23f
P
Pacini corpuscles, 48
Pain
with cerebral palsy, 344
with fractures
in wrists, 380-383
of hand wounds, 375-376
measurement tools, 376
Palmar aponeurosis, 40, 41f
Palmar grasps, 128-130, 256-258, 463
Palmar interossei muscles, 32-34, 35f
Parietal cortex
and hand-object interactions, 3-4
476 Index
Postural sway, 346
Posture
affected by cerebral palsy, 344
affecting handwriting, 298t, 301, 306
anticipatory, 346
and hand skill difculties, 247
and handwriting instruction, 230-231
importance of
in infant hand skill development, 122-124
in reaching, 93
inhibition and facilitation techniques, 349-351
and kinesthetic teaching techniques, 338, 341f
reflex-inhibiting, 344-347
relationship to upper extremity function
and cerebral palsy, 347-346
Power
and hand preference, 164
Power grip
denition of, 463
description of, 41
development of, 253-254
Praxis, 463
Precision grip
alteration with object sizes, 41f
denition of, 463
development of, 143
normal and impaired development
of force control in, 45-59
versus power grip, 4-5
types of, 43f
Precision handling
denition of, 463
and handwriting, 323, 324f
Preference; See hand preference; handedness
Prehensile force control
in children with central nervous system disorders, 45-46
sensory information used for, 57-58
Prehension skills
from 12 to 24 months, 136
from birth to 12 months, 127-130
denition of, 463
patterns of
versus manipulator patterns, 150
Premotor cortex
and hand-object interactions, 3-4
Preschoolers; See also children
ne motor program for, 267-287, 289-291
ne motor skills in
and visual perceptual inventory, 290-291
object manipulation in, 154-157
occupational therapy research studies, 449-450, 451t, 453454
scissors skills in, 279-280
Primary motor cortex
diagram of, 5f
role in hand movements, 5-7
summary and therapeutic implications, 16
use-dependent organization of, 5-7
Primary sensory cortex
connections to, 16, 17f
Primary somatosensory cortex; See somatosensory cortex
Priming
denition of, 104
Primitive grasps, 128-130
Primitive wound contracture, 368-369, 370b
Production Consistency Sheet, 329, 330f
Pronation
interventions to improve, 247-249
splints, 414
Proprioception
denition of, 463
description of, 48
role in reaching, 91-92
Proprioceptive systems
influencing hand skill development
in infants, 124-126
Prosthetic devices
for handwriting, 331, 332f
Proximal interphalangeal (PIP) joints
description of, 23
dorsal dislocation of, 384
Proximal phalanges
anatomical diagram of, 22f
description and position of, 22-23
embryonic development of, 21-22
ligaments of, 23, 24f
Proximal to distal development, 241
Proximal transverse arch
anatomical diagram of, 23f
description of, 22
Purposeful release, 131
Puzzles, 276
Q
Quadrupodgrasp, 280-281
R
Radial digital grasp, 251-253, 463
Radial nerve palsy
case study
on splinting, 423-425
Radial palmar grasp, 463
Radial-ulnar dissociation, 253, 463
Range of motion (ROM)
assessment of
in cerebral palsy patients, 352
in children and adolescents, 375
of hands
following wounds or injuries, 370-375
in infants, 372
neurodevelopmental approach to, 347
in toddlers, 372-373
types of, 370-373
upper extremity
and handwriting, 321, 324
Rapper snappers, 271
Reaching
and anticipatory control, 53, 94
case scenario concerning, 101-102
denition of, 89
and eye-hand coordination, 89-97
and hand preference, 164
importance of postural control in, 346
in infancy, 143
and motor impairments
adaptations, 96-97
in children, 96-97
with hemiplegic cerebral palsy, 97
planning and feedback control, 96
Index 477
Reaching (Continued)
movements
beginning stage, 92-93
coordinating body parts, 93
development during infancy, 92-95
integration of sensory information, 92
planning, 93-95
role of proprioception, 91-92
role of vision in, 91
sensory information, 95
speed, 89-90
transport and grasp phase, 90-91
variations, 95
and self-dressing, 205t
two main parts of, 12
Reflexes
control theories concerning, 46
Reflex-inhibiting postures (RIPs), 344-345
Regeneration
of tissue wounds, 368
Release; See object release
Repair
of tissue wounds, 368
Representation
denition of process, 102
Research evidence
on cerebral palsy, 435, 436t-440t
on hand function
in cerebral palsy patients, 436t-440t
on in-hand manipulation, 154-155
levels of, 433-434
summary of, 456-457
Retrieval phase
of explicit memory, 108
Reverse transverse grip, 463
Right handedness
consistent versus inconsistent, 168
denition of, 166b
Rotation skills, 257-259, 323, 324f, 463
S
Sandwich splints, 391f
Scaphoid
anatomical diagram of, 22f
description and position of, 22-23
fractures, 380-383
ligaments of, 23, 24f
Scar remodeling stage
of wound healing, 369, 370b
Scars
management of burn, 391-393
from radial club hand operations, 396-398
sandwich splints for, 391f
from syndactyly operations, 394-396
Scissors
illustration of cutting, 153f
motor functions of, 323
skill development
in preschoolers, 279-280
Scissors grasp, 463
Selective attention, 104
Selective posterior rhizotomy, 446
Self-care skills
acquisition of, 196-198
mastery motivation, 197-198
478 Index
Shoes
learning to tie, 209t, 210
and haptic perception, 63
Size
haptic perception of, 66
of objects
and anticipatory control, 52
Skiers thumb, 383-384
Skilled hand movements; See also movements
role of sensory information in, 8-9
Skilled tasks
versus unskilled, 164
Skills
acquisition of, 108-110
denition of, 108
Skin
of hands, 40, 41f
Smart Hands, 272-278
Social isolation
with cerebral palsy, 344
Somatosensory cortex
circuit of, 17f
and hand skills, 7-9
and hand-object interactions, 3-4
illustration of, 10f
role in grasp, 10-11
role in motor learning, 11-12
role in sensory function, 7-9
use-dependent organization within, 9-10
Somatosensory sensation
role in haptic perception, 69
Somatosensory system
cortical organization of, 8-9
denition of, 463
feedback
and graphomotor skills, 218-219
S.O.S. grids, 282
Southern California Sensory Integration Tests (SCSIT), 179180
Spasticity
with cerebral palsy, 344
biomechanics of, 350-349
denition of, 464
neurodevelopmental approach to, 345-346
surgical and medical interventions, 446-447
Spatial analysis
in handwriting, 327-328
Spina bida
affecting drawing abilities, 225
Spinal cord
ventral horn divisions of, 4-5
Splinting; See also splints
anti-Houdini techniques, 420b, 418f-420f, 419
benets of, 402-403
case study on radial nerve palsy, 423-425
common problems requiring
nger control, 414-415, 416f
sted hand, 411-412
neonatal intensive care, 415-417
supination and pronation, 414
thumb in palm, 411
weight bearing, 414, 415f
wrist flexion, 412-413
wrist ulnar and radial deviation, 413-414
efcacy of
research studies on, 443-444
Splinting (Continued)
fabrication for children, 410
history of, 401-402
as intervention adjunct, 262-263
material characteristics, 409-410
for orthopedic problems, 407t, 417-419
patient care instructions, 429-430
principles of, 402-403
selection of, 404, 405f, 406t-407t, 408-410
types of, 404, 405f, 406t-407t, 408
Splints; See also splinting
nger and thumb, 383-384
Kleinert, 385, 386f
for mallet nger, 384f
neoprene, 334f, 335, 382f
for tendon injuries, 385-389
vendors, 431
wearing schedules and precautions, 419
for wrist and elbow injuries, 380-382
Squeeze grasp, 464
Stability
affecting handwriting, 298t, 301, 306
denition of, 464
and grasp, 250
importance of wrist
in handwriting, 321-323
of materials
and grasp, 259f, 260-262
versus mobility, 241
and self-dressing, 205t
Stabilization; See stability
Static splinting, 404, 464
Static tripod grasp, 464
Stereognosis, 464
Stickers, 276
Stiffness, 464
Storage phase
of explicit memory, 108
Stringing activities, 273-275
Strong Hands, 272
Subcutaneous fascia
of hands, 40, 41f
Superior parietal lobes
diagram illustrating, 13f
effect of lesions in, 8f
functions of
and hand movements, 12-13
Supination
interventions to improve, 247-249, 251
splints, 414
Swallowing
and movements, 47
Swan neck deformities
splinting, 418f
Switched handedness
denition of, 166b, 464
intervention theories for, 182
problems associated with, 169b
theories concerning, 168-169
Symbolic play, 125
Syndactyly, 394-396
T
Tactile apraxia, 15
Tactile cues, 351
Index 479
Tactile perception
and brain injury, 81
impairments
and learning disabilities, 81-82
Tactile scanning, 63
Tactile system
awareness or discrimination, 246-247
denition of, 48
and friction, 53
identifying properties, 71b
importance of
in grasping and holding, 48-54
influencing hand skill development
in infants, 124-126
and motor control, 241-242
and object recognition, 69
Tapping, 171b, 172, 351, 464
Teaching
approaches to handwriting
efcacy studies, 451, 452t-453t, 454
principles and practices of handwriting, 319-342
bilateral integration, 326-327
kinesthetic approach to, 335-341
kinesthesia, 328-330
pencil grip, 330-331, 332f, 333-335
spatial analysis, 327-328
training groups, 319
upper extremity support, 320-321
visual control, 324-325
wrist and hand development, 321-324
to write name, 283b
Tendons
balance and biomechanical considerations, 35, 37
extrinsic
of hands and arms, 27, 28f-29f, 29-31, 32f
injuries to hand, 385-389
and intrinsic muscles
of hands, 31-35
movement with muscle contraction, 37
and proprioception, 48
Tensile strength
and wound healing, 369
Test of Handwriting Skills (THS), 302t-303t, 312-313
Test of Legible Handwriting, 304t-305t
Test of Motor Impairment (TOMI), 231, 448-449
Tests
for assessing handwriting, 302t-305t
Texture
haptic perception of, 66
identifying, 71b
The Development Test of Visual-Motor Integration, 227b
The Luria-Nebraska Neuropsychological Battery, 78
Therapeutic interventions; See interventions
Thermal hand injuries
in children
classication of severity, 392-394, 390t
closed wound scarring phase of, 392-394
open wound phase of, 390-392
patterns of, 389-390
Think breaks, 339f
Three-jaw chuck, 464
Threshold tests, 464
Thumb in palm, 406t, 411
Thumb spica splints, 382f
Thumb-index web space, 322
Thumbs
embryonic development of, 21-22
grip force rates, 56f
metacarpophalangeal joint of, 26-27
Ties, 208, 209t, 210
Tissue
burn scarring of, 391-394
regeneration of wounds, 368
Toddlers; See also children
complementary two-hand use by, 152-153
measuring pain in, 375-376
object manipulation by, 150-154
summary and therapeutic implications
of object manipulation skills, 153-156
Toileting, 210, 211t
Tone; See muscle tone
Tools
denition of, 198
features of skilled use of, 14-16
handwriting, 220
history of, 319
power grasps on, 253-254
role of inferior parietal cortex in use of, 14-16
and self-care activities, 198-210, 211t-212t
skills with
and hand preference, 164
stabilization of
hand structures needed for, 333b
Total end range time (TERT), 419, 464
Touch; See also tactile system
importance of
in grasping and holding, 48
Toys
Smart Hand, 272-278
types of
for ne motor skill development, 271-278
Tracing, 171b, 172, 282
Trajectory
denition of, 89
of reaching, 91
Translation, 464
Transport phase
of reaching, 90-91, 464
Trapezium
anatomical diagram of, 22f
description and position of, 22-23
ligaments of, 23, 24f
Trapezoid
anatomical diagram of, 22f
description and position of, 22-23
ligaments of, 23, 24f
Tripod grip
adapted, 331f
description of, 219-220
illustration of, 269f, 280f
training children in, 330-331
Triquetrum
anatomical diagram of, 22f
description and position of, 22-23
ligaments of, 23, 24f
Trunk
functions of
kinesiologic aspects of, 347-350
stability of
and self-dressing, 205t
480 Index
U
Unestablished handedness
denition of, 166b
intervention theories for, 180-182
Upper extremities
casting
research on efcacy of, 443-444
constraint therapy, 263
embryonic development of, 21-22
interventions for cerebral palsy
a neurodevelopmental treatment approach, 343-363
motor development tests, 195
splinting, 401-419, 420f-422f
case study, 423-425
and teaching handwriting, 320-321
and voluntary release, 254
Upper limbs
biomechanical interactions of
in cerebral palsy patients 350-349
functions of
kinesiologic aspects of, 347-350
Use-dependent organization
of inferior parietal and ventral premotor cortex, 14
within somatosensory cortex, 9-10
Utensils; See also tools
learning progression for using, 201, 202t, 203b
V
Vasoconstriction, 368-369, 370b
Vasodilation, 368-369, 370b
Velocity
illustration of rates of, 56f
Ventral premotor cortex
diagram illustrating, 13f
role in preshaping hand, 13-14
use-dependent organization of, 14
Ventral stream, 104, 464
Verbal rating scale (VRS)
to measure pain, 376
Vertical surfaces
examples of activities for, 269b
materials and suppliers, 289
teaching hand/wrist positions using, 268-269
Vestibular input, 351
Vibration, 144-145, 350, 353
Vision
and grasp preparation, 12-13, 16
influencing hand skill development
in infants, 119-120, 124-126
and manuscript versus cursive writing, 324-326
problems
with cerebral palsy, 344
role of
in graphomotor skills, 218-219
in haptic perception, 65-67, 74-75, 77
in object manipulation, 147-148
in reaching, 91
Visual analog scale (VAS)
to measure pain, 376
Visual motor control
evaluation of, 297-298
in handwriting, 324-326