OCCUPATIONAL THERAPY for Children

Enhancement of Grasp Skills

Problems: The following are problems in the development of effective grasp, some of which are illustrated in Figure 10-18:

FIGURE 10-18 When this child combines reach with grasp, he demonstrates significant difficulties with effective hand positioning. Note the slight wrist flexion, the thumb adduction with IP joint extension, and the finger MCP joint hyperextension with IP flexion that he uses in an attempt to achieve stability with this grasp. The arm positioning in abduction and internal rotation (not shown) contribute to use of this grasp pattern.

• Fisting or finger flexion that prevents hand opening

• Wrist flexion (often with ulnar deviation) in combination with finger extension

• Excessive forearm pronation, which interferes with the use of radial finger grasp patterns

• Thumb adduction in grasps that should use opposition, often with MCP or IP flexion

• Inability to use thumb abduction and adduction with MCP and IP extension

• Inability to initiate or sustain thumb opposition

• Inability to use grasp patterns that involve control of the intrinsic finger muscles

• Inability to vary grasp in accordance with object characteristics and activity demands

Goals: Presented next are examples of goals that can be used for children with a variety of levels of disability. The goals are in approximate order of difficulty, although difficulty using any one pattern can vary with the individual child. Some children may develop grasp only up to one of the lower levels identified here, whereas others may be able to attain the higher level skills. To illustrate how the goals associated with grasp may be integrated with occupations of the child or adolescent, sample occupations (in parentheses) are identified for each grasp. The goals are that the child will:

1. (Put on clothing, pick up a towel, play a game with large game pieces) using a sustained grasp with the arm in a variety of positions.

2. (Hold hard finger foods, pick up clothing, play with a car set) using a finger surface grasp on a variety of objects.

3. (Eat finger foods, use manipulative objects in math activities, play a game with small pieces, do a puzzle) using a finger pad grasp with thumb opposition on small objects.

4. (Prepare a meal, perform dressing tasks, perform hygiene tasks) using an opposed thumb and fingertip grasp pattern in accordance with object shapes and characteristics.

5. (Use a key to open a door, build with construction toys) using an effective lateral pinch grasp pattern.

6. (Handle computer materials such as paper and disks and file papers in folders; eat a cracker or sandwich) using finger pads to hold thin, flat objects.

7. (Brush the teeth, use a knife, comb the hair, and use a safety razor) using a power grasp.

Intervention Strategies: For children with delays and functional difficulties in grasp, the therapist needs to match preparation techniques, such as positioning, handling, or strengthening, to the child’s problem. Some children fist their hands or refuse to grasp objects because of tactile hypersensitivity, which also can influence the ability to maintain grasp. If this problem is present, grading tactile input from well tolerated to more difficult to tolerate is helpful. Initially, the child best tolerates firm objects with smooth surfaces and contours.

Tactile discrimination problems can contribute to grasp problems. Poor discrimination can affect dynamic use of grasp patterns and regulation of pressure in grasp. Problems with regulating pressure are seen as the child either holding objects with excessive force or dropping objects. Most children benefit from graded sensory input and attention to sensory discrimination as part of the intervention for grasp skills. Having the child actively explore the sizes, shapes, and textures of objects can precede emphasis on grasp in a treatment session.

In planning intervention that addresses grasp problems, the therapist, when selecting objects, should keep in mind the child’s interests, sensory needs, and motor skills. Properties to consider include the size, shape, color, weight, and texture of objects.

Children with Severe Disabilities: Children with severe disabilities need to develop an effective palmar grasp and, if possible, grasp patterns using the finger surface. If possible, the therapist should stress the abilities to initiate grasp and sustain grasp with the arm in a variety of positions. If the child is unable to open the hand readily for grasp, the therapist may explore whether changing the child’s body position would be helpful. The side-lying position may reduce stress on overall body posture and may make it possible for the child to open the hand more easily. In supported sitting, the child may find opening the hand easier if the therapist places an object below the seat of the chair and lateral to the child’s body. Boehme described other handling techniques that may assist the child with hand opening.¹² The therapist should follow these techniques with movement of the open hand across objects and surfaces as a way of increasing the child’s sustained hand opening and object interaction.

For the child who can independently open the hand but who shows wrist flexion with grasp, the therapist can emphasize wrist extension with grasp by positioning objects above the table surface or at chest height. Once the child can sustain wrist extension, the therapist can assist or encourage him or her to move the arm while maintaining grasp of an object. Sample activities using this skill include using a small stick to hit a suspended balloon or to break soap bubbles blown by the therapist, touching pictures on a wall or mirror with a stick, or holding onto clothing items while they are pulled up or down.

The child with a severe disability can wear a splint or other orthotic device during treatment and at other times of the day. Splinting techniques that may be useful in supporting hand function during treatment are described later in this chapter. Burtner et al. found that dynamic splints had a significant positive effect on grip over a static splint or no splint in a study that compared children with spastic cerebral palsy and typical children.¹⁵ Of note was a finding of compensatory movements at the shoulder when these children wore a static splint during grasp activities.¹⁵

In addition to the above strategies, many children need adaptations of materials to support their performance of activities at home, school, and play. Use of standard materials may not be possible. Built-up handles that accommodate a palmar grasp pattern and larger objects, such as game pieces and blocks, may be used instead of smaller ones. Adapted page turners for books, switches for toys, and computer adaptations may be necessary to give the child some independence in play and school activities.

Children with Moderate Disabilities: Children with moderate disabilities are able to grasp but have difficulty with functional use of a variety of grasp patterns. They have problems in forearm control, wrist extension, thumb opposition, and control of the MCP and IP joints (see Figure 10-18). Grasp may be initiated with wrist flexion. Grasp goals for these children usually are designed to address the use of opposed grasp patterns and grasp patterns in which the hand effectively accommodates to objects.

The occupational therapist selects specific object shapes, sizes, and textures to develop opposed grasp patterns. The therapist selects activities that are age appropriate, interesting, and meaningful to the child and have elements the child can repeat. Games and imaginary play materials can provide opportunities for repetitive presentation of objects to the child. The child can use opposed grasps with medium-sized, small, and tiny objects. Children often can demonstrate better thumb and finger control with small or medium-sized objects that have well-defined edges. Tiny objects require too much precision, such that the child often resorts to a more primitive grasping pattern. In fact, skill in using a pincer grasp usually is less critical for the child’s functional performance of daily life tasks than skill in using and varying a three-finger opposed grasp pattern. Once the child begins to acquire an opposed grasp pattern, the therapist can vary the objects by size, shape, texture, and weight.

The research findings of Case-Smith et al. support the clinical observation that object characteristics are important in eliciting specific grasp patterns, particularly when these patterns are emerging.²⁵ To help the child develop an opposed grasp pattern, the therapist can begin working on grasp alone rather than reach and grasp. The child’s arm should be well stabilized when objects are presented. Having the wrist in a neutral or slightly extended position is critical; if appropriate, the therapist can stabilize the volar surface of the child’s forearm on the table surface and give support over the dorsum of the forearm. The therapist should present objects in line with the shoulder and not at midline, because midline positioning has a tendency to encourage the use of pronation. With objects presented in line with the shoulder, neutral rotation of the humerus is encouraged (versus internal rotation) and slight forearm supination is likely to occur. The therapist holds the object with the fingers and presents the object directly to the child’s fingers (Figure 10-19, A). After grasp, the child carries the object to a nearby container or surface. Practice of this strategy for grasp, carry, and release using a variety of objects is needed for the child to integrate this skill.

FIGURE 10-19 A, The child shows the ability to use a controlled radial-digital grasp pattern with the wrist in a neutral position, thumb opposition, and appropriate finger flexion when he is not asked to combine reach with grasp. Note that the therapist’s presentation of the object helps ensure that the child will grasp the object with his fingertips. Her grasp also ensures that the object remains stable while the child initiates the grasp pattern. B, The child practices grasping from the therapist’s hand. His arm is stabilized on his leg during this grasp. The therapist’s hand provides some degree of stability to prevent the object from moving during initiation of grasp.

Once the child is able to use this pattern well, the therapist can move to the next skill level. At this level the therapist places the object in his or her cupped hand (just under the child’s hand and in line with the child’s shoulder), so that the object is stable, and asks the child to grasp the object (Figure 10-19, B). When the therapist uses this strategy, the child needs to use more internal stability of the arm and some degree of prepositioning of the fingers before grasp.

As the child develops skill in grasping from the therapist’s hand, the therapist can begin to place an object on the table surface. As at the prior two levels, the object is in line with the child’s shoulder, not at midline. The therapist may need to stabilize the object or place it on a nonskid surface for the child who does not have sufficient arm stability to grasp without unintentionally moving the object.

After the child is able to grasp from the table surface with the object in line with the shoulder, the therapist can begin to move the object further away on the table surface, above the table surface, and closer to midline. In this way the therapist is structuring activities to combine reach with grasp. This requires the child to stabilize the arm in space while controlling finger movements. The therapist may use a variety of these object placements in a therapy session to elicit the child’s best skills. Different object placements may be needed with various sizes and shapes of objects.

Using principles of motor learning theory, the therapist systematically varies object placement and the size and weight of objects during intervention activities. Varying the input enables the child to develop more adaptable, flexible skills that can be generalized to a variety of situations. Duff and Gordon noted that 7- to 14-year-old children with hemiplegic cerebral palsy were able to demonstrate anticipatory control (i.e., the ability to adjust the force needed to lift an object) with novel objects, given the ability to practice these grasp-lift patterns.³⁷ Their findings suggest that these children can develop an awareness of the object properties and the adjustment in force needed by practicing grasping and lifting objects of similar size but different weights. In addition, this ability can be achieved through practice of several grasp-lift repetitions with objects that have the same weight followed by repetitions with objects that have a different weight, or the weights of the objects can be varied randomly in a practice session.³⁷ The therapist can assess the type of repetition that seems to have the most positive effect for a particular child. Further study is needed to determine children’s retention of these skills over time. Gordon, Charles, and Steenbergen also found that children with cerebral palsy improved in their adjustment of the force necessary to lift an object via experiences with the opposite hand.⁶⁰ They were able to anticipate the force after using either the involved hand or the noninvolved hand. Thus, therapists should consider presenting objects for grasp to both hands, even if one is more impaired—and thus receiving more focus in therapy.

Children with Mild Disabilities: Children with mild disabilities typically have difficulty with small ranges of movement in supination and wrist extension. Sustained control with the intrinsic muscles of the hand may be difficult for these children to achieve. Fingertip control in grasp often is poor, as is the ability to control the palmar arches and to achieve radial-ulnar dissociation of movements within the hand. Some children substitute use of the middle finger for the index finger in attempting a pincer grasp (Figure 10-20); typical children may use this pattern occasionally, but children with tone problems (high or low) tend to use it frequently because of instability with the index finger and/or difficulty controlling the thumb in true opposition. Thus the thumb aligns more directly with the middle finger. This pattern can be functional for activities with tiny objects, but if the index finger cannot be used effectively with the middle finger, stable three-jaw chuck grasp patterns are not available for the child.

FIGURE 10-20 The child uses a substitution for a standard pincer grasp or tip pinch. Note that with slight adduction of the thumb, the pad of the thumb is more aligned with the middle finger than the index finger. The index finger is slightly too flexed to participate in the grasp.

Goals for grasp skills for these children usually focus on the use of a variety of grasp patterns, with accommodation of the grasp pattern to the object characteristics. These patterns include use of an effective pincer grasp and lateral pinch grasp pattern; use of a grasp with MCP flexion and IP extension to hold thin, flat objects; and/or use of a power grasp on a variety of tools in daily living tasks. The standard and lateral pinch patterns and the grasp for thin, flat objects require wrist stability and use of the intrinsic muscles.

The therapist can use a variety of treatment strategies with children who are working on these skills, including verbal cueing and structuring of activities to elicit intrinsic muscle activity. Sample activities include holding all fingers in adduction and extension while rolling out clay, using finger abduction to stretch rubber bands placed around two or more fingers, playing finger games that require isolation and small ranges of finger movements, holding or hiding objects in a cupped hand, and squeezing clay or other objects between the pad of the thumb and the pads of one or more fingers.

Development of a power grasp relies on the development of radial-ulnar dissociation and the ability to extend the index finger and thumb during ulnar finger flexion. Emphasis on radial-ulnar dissociation in the hand and on grasp with MCP flexion and IP extension is helpful as a precursor to the power grasp pattern. To address radial-ulnar dissociation, the therapist structures activities in which the child holds two objects in one hand and releases one at a time; holds an object in the ulnar side of the hand with the ring and little fingers while grasping and releasing with the radial fingers and thumb; and engages in activities that develop finger-to-palm translation with stabilization skills. In addressing the power grasp in functional activities, the therapist carefully selects the type of tool the child handles. Tools that have a narrow surface for index finger contact are particularly difficult for children to control. The therapist can use verbal cues, stickers, or dots on the handles of the tools to encourage appropriate finger placement. The child may need built-up handles to facilitate performance initially.

Enhancement of Voluntary Release Skills

Problems: Therapists usually combine treatment for voluntary release problems with intervention for grasp. Children who have difficulty releasing objects may exhibit the following:

• Fisting and tight finger flexion

• Difficulty with sustained arm position during object placement and release

• Difficulty combining wrist extension with finger extension

• Inability to use slight forearm supination to allow for release in small areas or near other objects and with visual monitoring of the placement

• Overextension of the fingers in release, limiting control of specific object placement

In their study of 7- to 13-year-old children with hemiplegic cerebral palsy, Eliasson and Gordon reported specific difficulties with both the placement phase and the release phase of object voluntary release.⁴³ The children’s replacement “is abrupt,” they said, “and their force coordination is impaired, resulting in a prolonged and uncoordinated release of the grasp” (p. 232).⁴³

Goals: Presented next are examples of goals the therapist can use for children with a variety of levels of disability. These goals specifically define the size of an area in which the child can release the object (e.g., into a container with a 4-inch opening) or the height of a surface on which the child can release the object (e.g., a stack of six cubes). The following goals incorporate these commonly used measures of voluntary release skill. The goals are in approximate order of difficulty, although difficulty using any one pattern can vary with the individual child. The therapist should integrate these goals with the child’s functional goals. The goals are that the child will:

1. Release objects into a container placed on the floor (e.g., pick up toys to put away [hard objects may be easier to use than soft objects]).

2. Release objects into a container placed on a table surface with the container at arm’s length from the child’s body to encourage wrist extension with finger extension (e.g., put objects into and take them out of a container).

3. Release objects into a container at the midline while using wrist extension (e.g., put pens and pencils into a basket after a group activity).

4. Release tiny objects into a container with a small opening (e.g., put nails or screws into a container after a project or put beads into a container for a beaded art project).

5. Place objects within 1 inch of other objects without making other objects move or fall (e.g., place game board pieces during a game, set the table with utensils).

6. Release unstable, lightweight objects while keeping them in an upright position (e.g., place objects on a desk at school and paper cups on the lunch table).

7. Release objects without visual monitoring (e.g., put a toothbrush into a container, pencils into a container, paper on a desk).

Intervention Strategies: Intervention focuses on one or more of the following areas, depending on the child’s problems: hand opening for object release, arm placement and stability for release, and accuracy of object placement. Releasing patterns correlate with grasping patterns. A child who uses a palmar grasp will use full finger extension to release the object. A child who uses a pincer grasp can use voluntary release with good control of the intrinsic muscles as balanced with the extrinsic muscles.

When the child shows excessive finger flexion (fisting), initial treatment for voluntary hand opening focuses on the child’s ability to move the arm while maintaining some finger extension. Splinting may be helpful in supporting the child’s wrist or facilitating increased wrist and finger extension. In children with fisting, asking the child to place the object into a container increases the child’s fisting. Some children have success releasing to the side of their body because movement away from the midline decreases the pronation-flexion posturing, thus increasing the hand fisting.

If the child can accomplish this level of voluntary release, he or she can attempt release of large and medium-sized objects into a container with a large opening that is placed on the floor. For some children, transfer of objects from hand to hand is a reasonable strategy for encouraging release with object stabilization.

Children who can voluntarily open their hands but who use tenodesis patterns may benefit from intervention to increase voluntary finger extension while maintaining the wrist in a neutral position. For some children, structured activities and handling are effective; other children benefit from wearing a dorsal wrist splint. A therapist can have the child wear a splint during part of the therapy session and encourage finger extension through a variety of activities, including voluntary release. The child can practice similar activities after splint removal.

Children who use wrist flexion with voluntary release may benefit from structured activities in which a container for objects is placed slightly lateral to the child’s midline and at a sufficient distance from the child’s body that the child needs to extend the elbow (Figure 10-21). This level of control is similar to that of an infant who releases objects with the arm held in a total extension pattern. Over time, the therapist can move the target containers closer to the child’s body, requiring gradually increasing elbow flexion with wrist extension for release of objects. Sometimes the therapist can facilitate this pattern if he or she sets the containers at an angle. Once the child can release medium-sized objects into a container at the midline while maintaining wrist extension to at least a neutral position, the therapist can reduce the size of the container opening.

FIGURE 10-21 Positioning materials to elicit elbow extension during release encourages the child’s use of wrist extension. (Courtesy Kanji Takeno, Towson University.)

Children with overextension of the fingers during voluntary release may benefit from activities described previously that address the development of intrinsic muscle control. They also may need intervention to improve somatosensory awareness of their hands. Activities for these children often incorporate the use of lightweight materials and objects that vary in size and stability. Verbal cueing of the child to attend to object and hand placement and graded activities to facilitate increasing accuracy and visual monitoring of materials are often helpful. Also, Gordon et al. observed that tasks that required increased accuracy (including object placement on a relatively unstable surface) could be used to encourage children with hemiplegia to slow their movements.⁶⁵ Instruction was helpful to the children in encouraging faster movements.⁶³ On the basis of findings from their studies, these researchers suggested that different speeds be used during voluntary release activities and that “practicing release tasks with the noninvolved hand first or practicing with bimanual tasks may enhance performance and should be studied” (p. 247).⁶³ In addition, the work of Eliasson and Gordon suggests that repetition of object release in which the object’s weight remains constant over a number of trials allows children with hemiplegic cerebral palsy to learn to adjust the release of grasp.⁴³ These findings provide support for the use of activities for voluntary release in which repetition and timing can be adjusted. Games of various types are often very effective for this purpose and are selected for the child’s cognitive level as well as the motor level.

Enhancement of In-Hand Manipulation Skills

Problems: Children who have difficulty with in-hand manipulation skills drop objects, use surfaces for support during manipulation, or are slow in the execution of skills.⁴⁵ Case-Smith found empirical support for these problems in her study of children with and without fine motor delays.²⁰ These problems are associated with tactile problems.¹⁹ Praxis and motor control problems, particularly of the intrinsic muscles, also may be a major cause of limited in-hand manipulation skill development. Attentional and cognitive problems contribute to these problems in some children. Problems that limit in-hand manipulation include the following:

• Limited finger isolation and control

• Inability to effectively cup the hand to hold objects in the palm

• Inability to hold more than one object in the hand at the same time

• Insufficient stability for controlling object movement at the finger pads, resulting in objects being dropped frequently

Goals: Presented next are examples of goals the therapist can use for children with a variety of levels of in-hand manipulation skill. The goals are in approximate order of difficulty, although difficulty using any one pattern can vary with the individual child. The activities, including additional examples in parentheses, require specific in-hand manipulation skills. The goals are that the child will:

1. Move coins (move finger foods) into the palm of the hand by demonstrating finger-to-palm translation.

2. Move several coins (move pieces of finger foods) into the palm of one hand by using finger-to-palm translation with stabilization skills.

3. Adjust coins for placement into a bank (adjust playing cards for a game) using shift skills.

4. Adjust eating utensils (adjust a toothbrush while cleaning the teeth) using simple rotation skills.

5. Eat small finger foods (setup/clean up a game board) using palm-to-finger translation (and palm-to-finger translation with stabilization).

6. Play with a building set (put caps onto markers) using simple rotation with stabilization skills.

7. Erase with a pencil (handle containers or lids) using complex rotation skills.

Intervention Strategies: The therapist’s assessment of the causes of the child’s problems and the therapist’s determination of the child’s potential for acquiring specific in-hand manipulation skills influence intervention goals and strategies. Many children with moderate and severe disabilities who lack the necessary prerequisite skills cannot develop in-hand manipulation skills. Children with mild disabilities usually can develop at least lower level in-hand manipulation skills.

Specific activity suggestions are given in Box 10-4. Suggestions for strategies therapists can use with children with different levels of skills are discussed next. Exner provides additional information on treatment of in-hand manipulation skills.⁴⁸

BOX 10-4 In-Hand Manipulation Activities

PREPARATION ACTIVITIES

1. Activities involving general tactile awareness

• Using crazy foam

• Using shaving cream

• Applying hand lotion

• Finger painting

2. Activities involving proprioceptive input

• Weight bearing (e.g., wheelbarrow, activities on a small ball)

• Pushing heavy objects (e.g., boxes, chairs, benches)

• Pulling (e.g., tug-of-war)

• Pressing different parts of the hand into clay

• Pushing fingers into clay or therapy putty

• Pushing shapes out of perforated cardboard

• Tearing open packages or boxes

• Playing clapping games

3. Activities involving regulation of pressure

• Tearing edges off computer paper

• Rolling clay into a ball

• Squeezing water out of a sponge or washcloth

• Pushing snaps together

4. Activities involving tactile discrimination

• Playing finger games and singing songs

• Playing finger identification games

• Discriminating among objects with the objects stabilized

• Discriminating among shapes with the shapes stabilized

• Writing on the body and identifying the shape, letter, or object drawn

• Discriminating among textures

SPECIFIC IN-HAND MANIPULATION ACTIVITIES

1. Translation (fingers to palm)

• Getting a coin out of a change purse

• Hiding a penny in the hand (magic trick)

• Crumpling paper

• Picking up a small piece of food and bringing it into the palm

2. Translation (fingers to palm with stabilization)

• Getting two or more coins out of a change purse, one at a time

• Taking two or more chips off a magnetic wand, one at a time

• Picking up pegs or paper clips one at a time and holding two or more in the hand at one time

• Picking up several utensils one at a time and holding two or more in the hand at one time

3. Translation (palm to fingers)

• Moving a penny from the palm to the fingers

• Moving a chip to the fingers to put on a magnetic wand

• Moving an object to put it into a container

• Moving a food item to put it in the mouth

4. Translation (palm to fingers with stabilization)

• Holding several chips to put on a wand, one at a time

• Handling money to put it into a coin bank or soda machine

• Putting one utensil down when holding several

• Holding several game pieces (chips, pegs, or markers)

5. Shift

• Turning pages in a book

• Picking up sheets of paper, tissue paper, or dollar bills

• Separating playing cards

• Stringing beads (shifting string and bead as string goes through the bead)

• Shifting a crayon, pencil, or pen for coloring or writing

• Shifting paper in the nonpreferred hand while cutting

• Playing with Tinker Toys (long, thin pieces)

• Moving a cookie while eating

• Adjusting a spoon, fork, or knife for appropriate use

• Rubbing paint, dirt, or tape off the pad of a finger

6. Shift with stabilization

• Holding a pen and pushing the cap off with the same hand

• Holding chips while flipping one out of the fingers

• Holding fabric in the hand while attempting to button or snap

• Holding a key ring with the keys in hand, shifting one for placement in a lock

7. Simple or complex rotation (depending on object orientation)

• Removing or putting on a small jar lid

• Putting on or removing bolts from nuts

• Rotating a crayon or pencil with the tip oriented ulnarly (simple rotation)

• Rotating a crayon or pencil with the tip oriented radially (complex rotation)

• Removing a crayon from the box and preparing it for coloring

• Rotating a pen or marker to put the top on it

• Rotating toy people to put them in chairs, a bus, or a boat

• Rotating a puzzle piece for placement in the puzzle

• Feeling objects or shapes to identify them

• Handling construction toy pieces

• Turning cubes that have pictures on all six sides

• Constructing twisted shapes with pipe cleaners

• Rotating a toothbrush or eating utensils during use

8. Simple or complex rotation with stabilization

• Handling parts of a small-shape container while rotating the shape to put it into the container

• Holding a key ring with keys, rotating the correct one for placement in the lock

Children with No In-Hand Manipulation Skills: The therapist may encourage the child with no in-hand manipulation skills or only finger-to-palm translation to manipulate objects between the two hands and use support surfaces to assist in object manipulation. Use of these strategies can help the child begin to move the fingers actively over object surfaces. The therapist can use objects such as cubes that have pictures on all sides, kaleidoscopes, and textured toys. When the child can effectively move the fingers over objects, the therapist can introduce finger-to-palm translation activities in the context of “hiding the object” games using various objects. Finger isolation games can be useful, and the therapist should incorporate the thumb into these activities. The child should be assisted in developing and functionally using a variety of grasp patterns, including those that combine flexion at the MCP joints with extension at the IP joints. The therapist can use tactile discrimination and proprioception activities to enhance awareness of fingers and areas of the palm of the hand.

Children with Beginning In-Hand Manipulation Skills: Children who can use finger-to-palm translation and beginning simple rotation, or shift, or palm-to-finger translation skills can work on refining these skills, expanding their repertoire of skills used without stabilization, and beginning their ability to stabilize objects in the ulnar side of the hand while manipulating with the radial fingers.

Object selection for in-hand manipulation skills with these children is important. Objects that do not roll and that are small (not tiny) are often the easiest for the child to handle. Examples are dice-sized cubes, nickels, game pieces, and other small toys. With larger objects, the child must involve all fingers in the manipulation and must use more hand expansion; therefore, these objects are more difficult for the child to handle. With tiny objects, the child must have excellent tactile discrimination and fingertip control, which also makes these objects more difficult to handle than small objects.

The therapist structures the presentation of objects to assist the child in using a particular in-hand manipulation skill and often cues the child in the use of the skill. In a study of preschool children without disabilities who had emerging in-hand manipulation skills, Exner found that use of verbal cues or demonstration of skills had a positive effect on the children’s scores (as a group).⁴⁶ However, children with lower scores showed more improvement with cues than children with higher scores. These findings suggest that verbal cueing may be an important component of intervention for in-hand manipulation skills. The Cognitive Orientation to Occupational Performance (CO-OP) approach encourages the therapist to provide verbal cues and the child to select his or her own goals and strategies and to talk his or her way through an activity as a method of increasing coordination and motor planning.

In addressing palm-to-finger translation, the therapist first places the object on the middle phalanx of the child’s index finger. When the child is able to move the object from this position out to the pads of the fingers, the therapist places the object on the volar surface of the proximal phalanx of the index finger. Later the therapist places the object in the palm of the child’s hand to promote thumb isolation and control to move the object.

The therapist can structure simple rotation skills by placing the object in the child’s hand (in a radial grasp pattern) and asking the child to turn it upright (Figure 10-22). Pegs and peglike objects (e.g., candles and objects that look like little people) can be helpful in developing these skills.

FIGURE 10-22 The peg has been placed in the child’s hand upside down to encourage rotation prior to placement in the game board.

Finger-to-palm translation with stabilization is the one skill with stabilization that is likely to be feasible for these children. This child often can facilitate this skill during finger-feeding activities and in play with coins. The therapist first encourages the child to hold one object in the hand while picking up and hiding another. After the child can manage two objects, the therapist can progress to using three or more objects.

Children with Basic In-Hand Manipulation Skills: For children with basic in-hand manipulation skills, the therapist emphasizes the development of complex rotation skills (Figure 10-23) and the use of stabilization with the other skills. The therapist introduces small and medium-sized objects and emphasizes use of the skills in a variety of functional activities, including dressing, hygiene, and school tasks. The child practices combinations of skills, such as finger-to-palm translation, palm-to-finger translation, and simple rotation. The therapist also can stress speed of skill use by timing skills and reporting the speed to the child. Children who are working at this level of skill typically respond well to verbal cueing for strategies to use in performing skills and to feedback about the effectiveness and speed of their skills. Eliasson, Bonnier, and Krumlinde-Sundholm studied the impact of practice of shift skills with a pen by adolescents who have cerebral palsy.⁴¹ Eight of the nine adolescents showed improvements in use of this skill after a 2-week period of daily practice and retention of the skill 5 months later by five of the adolescents. Three adolescents had some loss of skill at the 5-month time period; however, none returned to their original performance level. The only adolescent to show no change with intervention had a 0 score (of 8) on the initial assessment, but three other children with initial performance at this level did show improvement in in-hand manipulation skills.

FIGURE 10-23 A, The child is forming a picture with a set of puzzle blocks. He is encouraged to find the side of the block that fits 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 find it. B, Prior to using the in-hand manipulation skill of complex rotation, the child must use palm-to-finger translation to move the block toward the distal finger surface. In that process the block begins to be turned. C, Having identified the correct side, the child shifts the object out to the pads of the fingers prior to placement with the other blocks.

Facilitation of Bilateral Hand Use Skills

Problems: Difficulties with bilateral hand use result from a combination of problems, of which motor factors are only one component. Some children with significant cognitive delays cannot attend to two objects simultaneously; therefore, reciprocal hand use or stabilization with one hand combined with object handling by the other hand is challenging and may not be possible. Children may exhibit deficits in integration of the two body sides, and some children have impaired sensation with a lack of attention to one body side. Lack of bilateral motor experience, as with hemiplegia or after brachial plexus injuries, can cause children to approach all tasks in a one-handed manner. Other problems may include the following:

• The child cannot effectively sustain both hands at the midline.

• The child has difficulty using supination during bilateral activities.

• The child has overflow movements and associated reactions in one upper extremity when using the other.

Goals: Presented next are examples of goals the therapist can use for children with a variety of levels of disability. These goals fit the categories of gross symmetrical bilateral skills, stabilizing or manipulating with one hand while manipulating with the other hand, and bilateral simultaneous manipulation. The goals are listed in increasing level of difficulty, consistent with a developmental approach. This progression in skills may not be appropriate for children with significant weakness or motor problems on one body side. The goals are that the child will:

1. Push large objects using both hands together.

2. Lift and carry large objects using both hands.

3. Lift and carry medium-sized objects using both hands.

4. Color (write), demonstrating the ability to stabilize. materials on a table surface with one open hand while the other hand manipulates materials.

5. Hold the handle of a small pan while pretending to cook (hold the edge of a puzzle box while putting pieces away, hold the handle of a small bucket while filling with water), demonstrating the ability to stabilize materials using a palmar grasp while the other hand manipulates materials.

6. Hold a cup while pouring liquid into it (hold a slice of bread while spreading butter on it, hold a marker box while putting the markers away), demonstrating the ability to stabilize materials using a variety of grasp patterns while the other hand manipulates materials (Figure 10-24, A).

FIGURE 10-24 A, This child shows the bilateral skill of stabilizing with a refined grasp with her left hand while placing a penny in the bank with her right hand. Note the appropriate use of force in holding both objects. B, Bilateral manipulation occurs with both hands in this construction activity. The child uses modifications of the power grasp with different forearm positions on the right and left while connecting two parts of the toy.

7. Button (tie shoes, fix hair, complete a mechanical project), demonstrating the ability to manipulate objects with both hands simultaneously (Figure 10-24, B).

Treatment goals vary depending on the severity of the child’s disability and the level of skills the child is expected to acquire. The therapist must consider the child’s need and potential for gross symmetrical hand use, stabilizing with one hand while manipulating with the other, and bilateral simultaneous manipulation.

Intervention Strategies:

Children with Severe Disabilities: Intervention for the child with significantly increased tone or marked asymmetry focuses on promoting the child’s ability to stabilize materials with the more involved hand while manipulating with the more proficient hand. Activities that require stabilization with grasp are often easier for these children than are symmetrical bilateral skills or stabilization without grasp. However, the child can accomplish stabilization without grasp as long as he or she can use the hand in a fisted position with the wrist in neutral to slight extension. Activities that elicit symmetrical bilateral hand use can increase awareness of one arm to increase movement and/or control of that arm. Simultaneous bilateral manipulation skills usually are inappropriate for these children unless the therapist can use adaptations.

Special handling techniques can promote the child’s ability to stabilize objects while manipulating them or to use gross bilateral skills. The therapist can sit behind the child and stabilize both shoulders to help the child bring and keep both hands at the midline. The therapist should also encourage trunk rotation so that the child can cross the midline effectively.

Toys and materials selected for bilateral activities must require both hands to be used, particularly in the early phases of treatment. Initially the child may be more successful with gross bilateral skills if he or she can sustain grasp and keep the forearms pronated, such as in holding a stick horizontally to hit a balloon. Expecting bilateral hand use to occur with the forearms in supination to midposition may be far too difficult for the child.

For the child who is working on stabilizing with one hand while manipulating with the other, presenting objects on a slippery surface may require the child to use one hand as a stabilizer. Objects that have handles are useful when the therapist is working on stabilization with grasp. Activities that are simple for the manipulating hand can allow the child to focus on the role of the stabilizing hand. Usually the therapist places materials for bilateral skill development at the midline. However, the therapist and the child should explore other positions if midline positioning is not optimal.

If a child cannot successfully stabilize materials and does not show potential for this skill in the near future, the therapist should consider adaptations. Nonskid surfaces and other devices can assist in stabilization of materials for table activities.

Children with Moderate Disabilities: Intervention for children with low tone or some degree of involuntary movement can approximate the normal sequence of bilateral hand skill development. Therapy initially focuses on improving symmetry and stability and proceeds through developing the child’s skills in stabilizing with and without grasp. Children at this skill level may benefit from working on a slightly unstable surface to prompt spontaneous stabilization of materials during manipulation. The child may need adaptations for certain highly demanding activities (e.g., handwriting) in which one hand must be an effective stabilizer. Generally, simultaneous bilateral manipulation is not feasible for these children.

Children with Mild Disabilities: Children with mild disabilities may require further refinement of gross symmetrical bilateral skills and stabilizing with one hand while manipulating with the other. These children can also develop or improve their simultaneous bilateral manipulation skills. To enhance development of simultaneous bilateral manipulation skills, the therapist carefully selects, grades, and structures a variety of activities that elicit these skills. The therapist may also use functional activities of daily living to facilitate development of these skills.

Children with Muscle Weakness: Children with muscle weakness can often manage simultaneous manipulation activities well because little hand strength and movement of the arms against gravity are required. These children often need assistance or adaptations to develop the ability to stabilize materials with one hand because this demands more strength in the stabilizing arm. The child may be able to accomplish gross symmetrical bilateral skills only on table surfaces that provide arm support.

RESEARCH ON INTERVENTION FOR HAND SKILL PROBLEMS

Studies on the efficacy of fine motor and hand skill intervention in children increasingly are providing information that is useful in the determination of intervention strategies and the planning of occupational therapy programs. However, currently almost all studies have looked at the short-term benefits of intervention. Longer-term and longitudinal studies are beginning to emerge.

A study by Heathcock, Lobo, and Galloway with full-term and preterm infants involved caregiver-provided interventions performed for approximately 75 to 100 minutes per week for 8 weeks.⁶⁹ They found that the infants who received intervention in which reach and hand contact with objects were facilitated demonstrated a significant positive difference in these skills when compared to infants who were provided with a social intervention. The motor intervention was identified as affecting frequency and consistency of these skills as well as some aspects of quality. Thus, although certain elements of the preterm infants’ reach and object contact skills were noted to differ from the full-term infants, the motor intervention had a positive effect. It should be noted that outcomes were assessed during the intervention; retention of these improvements after the intervention concluded was not reported.

Case-Smith has conducted a number of studies designed to assess the effectiveness of school-based occupational therapy on improvement in children’s hand skills. In a study designed to assess the outcomes of occupational therapy programs for 26 preschool-age children who were treated during one school year, Case-Smith found that the children showed significant change in several aspects of fine motor skills, including in-hand manipulation skills, motor accuracy, and tool use.²¹ In addition, the children showed significant improvement in their self-care skills. In a follow-up study with a larger group of preschool-age children with problems and a group of children without problems, Case-Smith et al. compared children who received services with those without problems.²⁵ The children who received services made significant progress in the areas of in-hand manipulation skills and motor accuracy. The researchers also found that more consultation was significantly associated with the children’s improvement in some fine motor skills.

A subsequent study by Case-Smith included 38 children of elementary school age (7 to 10 years old) who had handwriting difficulties.²² Data were collected regarding the children’s in-hand manipulation skills as well as their handwriting skills. As a group, the 29 children who had received occupational therapy services across the school year (i.e., a 7-month period) showed more improvement in in-hand manipulation speed than the group of 9 children who did not receive occupational therapy. The occupational therapists who provided the services to these children reported that they included object manipulation activities in their weekly 30-minute treatment sessions with the children. This study, as well as Case-Smith’s 1998 study, is particularly valuable in supporting intervention for in-hand manipulation problems in children in that even in studies in which the intervention was not highly controlled (in which different therapists provided treatment activities that varied based on the child’s needs), in-hand manipulation skills have been shown to improve. Such studies suggest that children with mild involvement can make significant changes in these skills with occupational therapy intervention. Further studies are needed to determine more specifically the impact of such improvement on occupational performance in the children.

A study by Schoemaker, Niemeijer, Reynders, and Smits-Engelsman similarly supports intervention for children with mild disabilities.¹²⁰ Children with developmental coordination disorder were placed in a treatment group (n = 10) or a control group (n = 5). The experimental group received 18 treatment sessions of “a task-oriented treatment program based upon recent insights from motor control and motor learning research,” and the control group did not receive treatment (p. 155).¹²⁰ The children who received treatment improved significantly in handwriting quality and in dexterity and ball skills performance on the Movement Assessment Battery for Children (ABC). The authors noted that some of the changes were quite substantial and seemed to be related to whether a skill was practiced or not. Although no follow-up data were reported, this approach seems to be worthy of further study in children with DCD as well as other types of motor coordination difficulties.

In 2001, Mandich, Polatajko, Macnab, and Miller presented a critical analysis of the research available at that time related to effectiveness of interventions for children with DCD, particularly “focusing on the extent to which treatments improve the child’s motor performance in daily activities such as bike riding, shoe tying, handwriting, and hitting a baseball” (p. 54).⁹¹ Functional skills such as these are often identified by both children and parents as problematic and areas of desired improvement. The literature they analyzed included studies in which intervention focused on (1) identified underlying problems (“bottom-up approaches”) such as sensory integration, process-oriented treatment (which focuses on kinesthesia in interventions), perceptual-motor training, and combined approaches, or (2) interventions that focus more directly on the task/skill desired such as task-specific intervention and cognitive approaches. They conclude that

… although the bottom up approaches have a long tradition, the empirical data do not convincingly support their effectiveness in improving the motor skills of children with DCD, nor do they support the assumed relationship between underlying processes and functional performance… [in contrast] early evidence for the use of top down approaches with a DCD population, and collateral evidence from other populations, suggests that these approaches may be very effective in teaching specific tasks and in improving the functional performance of children with DCD (p. 65).⁹¹

Generalization of skills learned via these approaches need further study. They concluded that use of motor learning theories with functional skills may be a strategy that will be useful with children who have DCD.

Miller, Polatajko, Missiuna, Mandich, and Macnab presented the findings of their pilot study using CO-OP with this population (see Research Note 10-2).⁹⁸ CO-OP emphasizes problem-solving strategies and guided discovery of child- and task-specific strategies. The child identifies the specific occupational tasks to be learned and then discovers and practices strategies for performing the task. As Candler and Meeuwsen noted, “Children with developmental coordination disorder can implicitly recognize and respond to environmental cues important to task performance” (p. 434).¹⁷ These children do not necessarily benefit from highly specific cueing of their performance.

In Europe an intensive approach to treatment, referred to as conductive education. is used with some children who have cerebral palsy. This approach is described as “a combined therapeutic and pedagogic program”¹¹ with a focus on engagement in specific tasks, use of rhythmic speech, application of specific hand skills in daily activities, and group activities with other children. In the study by Blank et al., children participated in the conductive education program 7 hours a day for 4 weeks on three occasions within a 9-month period.¹¹ The other form of intervention was considered standard with a minimum of 2 hours of therapy weekly. The authors found that both the preferred and nonpreferred hands showed more improvement in coordinated hand use and independent living skills that rely on hand use than in basic hand functions and that these positive changes were noted by parents as well. Although this model was shown to be effective in this study of 64 children, it is an extremely intensive program that is not readily available either in terms of personnel trained in this approach and/or in the opportunity to participate in a program requiring such intensive involvement.

Research of children with more substantial motor disabilities has documented evidence of intervention effects (e.g., see the review by Boyd, Morris, and Graham¹³). Fedrizzi, Pagliano, Andreucci, and Oleari conducted a longitudinal study with 31 children with spastic hemiplegia in which they assessed the children for grip skill and use of the more involved hand in bilateral activities.⁵² From the time of the initial referral to age 4, the children received individual therapy two or three times a week, then from 4 to 7 years of age the children received small group treatment (three or four children per group). Therapy focused on improvement of hand skills through the use of motor learning principles in play and activities of daily living. These authors’ findings support intervention focused on use of the hemiplegic hand in functional activities for these children. In fact, the greatest improvements in grasp were found to occur during the years of small group treatment (ages 4 to 7). However, this change may have been due to developmental readiness for improvement in grasp at that time; further study would be needed to determine whether the change was associated with the specific treatment. The authors noted that the more involved hand was more impaired in spontaneous bilateral activities than when used alone in grasping skills. The children in their study with the most severe motor disabilities (a small number of children) tended to deteriorate in grasp skill as they approached adolescence. These authors recommended monitoring of children with more severe involvement in this age group to determine the need for continued intervention.

Constraint-Induced Movement Therapy for Children with Hemiplegic Cerebral Palsy

Children with hemiplegic cerebral palsy demonstrate limitations in bilateral hand use.⁵² Sterr, Freivogel, and Schmalohr documented differences in available movement/skill versus spontaneous use in children and young adults with hemiplegia.¹³¹ They found that although these individuals were able to use their involved hand, they tended not to do so and that they believed they had more ability to use their hands than they actually demonstrated. Therapists therefore have often sought a variety of strategies to increase spontaneous use of the involved hand.

Taub’s research has provided the basis for clinical application of constraint-induced movement therapy, which is now used with adults and children with hemiplegia in a number of clinical settings.¹³⁴ A key characteristic of this therapy is the use of some method of restraint of the less involved arm and hand to promote use of the more involved arm and hand. Implementation of this intervention with children varies in the method used to restrict movement in the less involved arm and hand, in the amount of intervention provided during the restriction of movement, and the number of days or weeks of restriction. Some researchers report using a splint on the less involved hand^30,⁵⁹; others report using casting of the less involved arm and hand.^35,¹⁴⁵ In the studies (which may reflect clinical practice models), some children were provided with no additional specific intervention,^30,¹⁴⁵ others received additional therapy sessions during the days of restricted movement of the less involved hand,⁵⁹ and still others received 6 hours of intervention per day during the casting.³⁵ The most common time frame reported in the research studies was 3 to 4 weeks.^30,^35,¹⁴⁵ The one factor that appeared to be relatively constant in implementation of this intervention is restriction of the less involved hand for at least 6 waking hours a day.

Crocker and others used a single case study to evaluate the effectiveness of this approach with a 2-year-old child.³⁰ Outcomes immediately after splinting and 2 weeks later included more arm-hand use with better quality, as demonstrated in play, finger feeding, and PDMS Fine Motor Test results. Six months later, additional improvement was noted.

Glover et al. assessed constraint-induced movement therapy in a 19-month-old child.⁵⁹ Changes noted were significant in frequency of arm-hand use, accuracy of movements, and strength. Spontaneous use in bilateral activities and quality of reaching and voluntary release were evident, but grasp was not substantially improved. Although spasticity was diminished immediately on discontinuation of the constraint-induced movement program, it did return gradually. At 2½ months after intervention, spontaneous use remained improved.

Another case study to assess constraint-induced movement therapy was conducted by DeLuca et al. with a 15-month-old girl.³⁵ In this study, the researchers provided a second session of this therapy 5 months after the end of the first session. Positive changes in the child’s arm-hand use and major changes in the spontaneity of her use of the more involved hand resulted. She showed significant improvement in occupational performance activities appropriate for her age.

A group comparison study of constraint-induced movement therapy in children between the ages of 1 and 8 years was conducted by Willis et al.¹⁴⁵ Using a cross-over design, half of the children received casting and intervention for a month, then after a 6-month period the other half received casting and intervention. During each of the study time periods, the children who were casted improved approximately 10 points more on the PDMS than those who were not casted. All parents of the children casted also documented improvement.

Constraint-induced movement therapy, therefore, seems to be a potential adjunct to other interventions for children with asymmetric motor involvement due to CNS dysfunction. All children studied showed improvement in one or more aspects of neuromusculoskeletal and movement-related functions, performance skills, and occupational performance. However, some authors noted the parents’ concern, at least initially, with the constraint regarding the loss of independence in activities they previously could accomplish since the children were unable to use their preferred hand³⁵ and because of the children’s level of frustration.⁵⁹ However, the parents also noted substantial improvements in their children’s functioning as a result of participation in this type of intervention. Therefore psychosocial support for the parents and the child seems imperative with constraint-induced movement therapy.

In response to some of the aforementioned concerns, Gordon, Charles, and Wolf have modified the constraint-induced movement therapy protocol for children over time, with a commitment to making it as child-friendly as possible.⁶¹ Rather than a cast, a sling is used in their studies. The intensive intervention includes activities for the involved arm and hand during 10 of 12 consecutive days. Activities are selected to allow for progressive shaping of responses and multiple repetitions of each movement pattern. Their program has been used with 37 children in the 4- to 14-year-old age range and is conducted in small groups. In addition to describing the program, they include information regarding consideration of other factors and assessment of outcomes. Hart outlines key issues to be addressed in subsequent studies of this approach with children.⁶⁸ In all cases the intervention has been found to be effective, suggesting that intensive intervention focused on graded approaches to building hand skills yield results that are sustained over time. Although the children in these studies continue to have difficulties with hand use, their function after this intervention is demonstrably improved (Table 10-2).

TABLE 10-2

Evidence Table and Research Summary: Constraint-Induced Movement Therapy (CIMT) & Hand-Arm Bimanual Intensive Training (HABIT)

Charles, J. R., Lavinder, G., & Gordon, A. M. (2001). Effects of constraint-induced therapy on hand function in children with hemiplegic cerebral palsy. Pediatric Physical Therapy, 13(2), 68-76; Charles, J. R., Wolf, S. L., Schneider, J. A., & Gordon, A. M. (2006). Efficacy of a child-friendly form of constraint-induced movement therapy in hemiplegic cerebral palsy: a randomized control trial. Developmental Medicine & Child Neurology, 48(8), 635-642; DeLuca, S. C., Echols, K., Ramey, S. L., & Taub, E. (2003). Pediatric constraint induced movement therapy for a young child with cerebral palsy: Two episodes of care. Physical Therapy, 83, 1003-1013; Eliasson, A. C., Krumlinde-Sundholm, L., Shaw, K., & Wang, C. (2005). Effects of constraint-induced movement therapy in young children with hemiplegic cerebral palsy: an adapted model. Developmental Medicine & Child Neurology, 47(4), 266-275; Elisasson, A. C., Bonnier, B., & Krumlinde-Sundholm, L. (2003). Clinical experience of constraint induced movement therapy in adolescents with hemiplegic cerebral palsy—a day camp model. Developmental Medicine & Child Neurology, 45(S(99)), 18; Gordon, A. M., Charles, J. R., & Wolf, S. L. (2005). Methods of constraint-induced movement therapy for children with hemiplegic cerebral palsy: development of a child-friendly intervention for improving upper-extremity function. Archives of Physical Medicine & Rehabilitation, 86(4), 837-844; Gordon, A. M., Chinnan, A., & Charles, J. R. (2007). Efficacy of a hand-arm bimanual intensive therapy (HABIT) in children with hemiplegic cerebral palsy: a randomized control trial. Developmental Medicine & Child Neurology, 49, 830-838; Gordon, A. M., Chinnan, A., Gill, S., Petra, E., Hung, Y. C., & Charles, J. R. (2008). Both constraint-induced movement therapy and bimanual training lead to improved performance of upper extremity function in children with hemiplegia. Developmental Medicine & Child Neurology, 50(12), 957-958; Pierce, S. R., Daly, K., Gallagher, K. G., Gershkoff, A. M., & Schaumburg, S. W. (2002). Constraint induced therapy for a child with hemiplegic cerebral palsy: A case report. Archives of Physical Medicine & Rehabilitation, 83, 1462-1463; Taub, E., Griffin, A., Nick, J., Gammons, K., Uswatte, G., & Law, C. R. (2007). Pediatric CI therapy for stroke-induced hemiparesis in young children. Developmental Neurorehabilitation, 10(1), 3-18; Taub, E., Ramey, S. L., DeLuca, S., & Echols, K. (2004). Efficacy of constraint-induced movement therapy for children with cerebral palsy with asymmetric motor impairment. Pediatrics, 113(2), 305-312; and Willis, J. K., Morello, A., Davie, A., Rice, J. C., & Bennet, J. T. (2002). Forced use treatment of childhood hemiparesis. Pediatrics, 110(1), 94-96. Courtesy Sandra Rogers.

SPLINTING

Splinting is often a component of occupational therapy intervention for children with hand function problems. Children who have one or more of the following problems may benefit most:

• Sustained abnormal posturing

• Increased tone or markedly decreased tone

• Limitations in movement of the hand

• Limitations in functional skills secondary to problems with hand functions

Children with severe motor disability associated with CNS dysfunction may benefit from splinting to reduce tone or improve mobility and functional skills. The child with minimal involvement secondary to CNS damage may have more difficulty with thumb use than with wrist or finger control. This child may need a thumb splint to diminish flexor muscle tone or to provide thumb MCP stability so that function is enhanced.

This section presents an overview of splinting for children with disabilities. Gabriel and Duvall-Riley provide additional information on the selection of splints and more specific details about construction of a wide variety of splints for children.⁵⁶

Precautions and Indications for Splint Use

Precautions for splint use are always in order, particularly for nonverbal children who may have poor sensation. These factors make them vulnerable to skin irritation and pressure problems. Children may be unable to report sensory problems during or after splint application; therefore the therapist must carefully instruct the child’s parents regarding the wearing schedule, possible problems, and postural changes to note.

Static splints generally are worn for shorter periods than splints that allow hand movement. Initially children may tolerate wearing a splint for only 5 to 10 minutes. Usually the therapist can gradually increase these periods. If the child has increased tone, maximum wearing time for a static splint is usually 6 to 8 hours per day. However, if splints allow some hand movement and the therapist uses them to aid accomplishment of functional activities, the child may tolerate them for additional hours.

Children generally wear night splints all night, but they should spend at least a part of each 24-hour period without the splints. Not all children with increased tone need night resting splints. In many cases their hands are more relaxed during sleep, and their parents can arrange their arms and hands in neutral position. Children who have neutral positioning at night generally are at less risk for the development of contractures. However, the child who shows abnormal hand posturing during the day but not at night may require daytime splint application to increase function.

Boehme noted that some children have learned to use abnormal patterns of wrist flexion and ulnar deviation or thumb adduction to accomplish their daily activities.¹² If a splint inhibits this pattern, the child may compensate by using another abnormal position of the hand or arm. Therefore before the therapist applies a splint, he or she must determine whether functional skill patterns that the child is using will be lost. Often the therapist needs to increase the frequency of intervention sessions when children are wearing splints so that they can develop better patterns of hand use.

Types of Splints Used with Children

Splints are categorized as those that allow hand movement and those that do not. Static splints include resting pan splints, other volar and dorsal full hand and wrist splints, spasticity reduction splints, and thumb positioning splints. Dynamic splints assist the child with a particular wrist, finger, or thumb movement. A neurophysiologically based splint may provide stimulation to the hand or arm or assist with stabilization of one or more joints during hand or arm activities.

Doubilet and Polkow³⁶ and Snook¹²⁹ reported case studies suggesting that spasticity reduction splints help decrease tone in adults. McPherson examined the effectiveness of Snook’s spasticity reduction splint in five adolescents with severe disabilities.⁹⁸ Splint-wearing time was gradually increased from 15 minutes the first day to 2 hours daily by the fourth week. The outcome measure was passive muscle tone at the wrist, which was documented on a daily basis through use of a scale that measured pounds of force when the individual assumed wrist flexion. During the 4 weeks of splint application, the subjects’ wrist tone decreased significantly. When they did not wear the splints for a week, their tone increased again.

When the therapist applies spasticity reduction splints, he or she should take care to control the thumb MCP joint. Distal force on the thumb can result in stretching or even rupture of the ulnar collateral ligament of the thumb’s MCP joint¹⁰⁹ and subluxation of the MCP joint. Because children with spasticity usually demonstrate marked thumb adduction, distal control of the thumb moves the MCP and IP joints into hyperextension; therefore control at the carpometacarpal (CMC) joint is needed to abduct and extend the first metacarpal CMC joint.

Resting pan splints may provide more support to and control of the thumb than some of the spasticity reduction devices. However, the therapist should plan and monitor splints carefully for reactions at the wrist and fingers. Children with increased tone may not tolerate the classic position for a resting hand splint, in which the wrist is in 20° to 30° of extension and the fingers are in slight flexion. The child with moderately increased tone may have more tolerance for a resting splint that holds the wrist in neutral position and the fingers in slight flexion. However, if flexor spasticity is severe, splinting that begins with the wrist in marked flexion and emphasizes slightly increased finger extension (out of full fisting) may be most effective. Initially the therapist should stabilize the wrist position in just slightly more extension than the child normally achieves. The therapist then adjusts or reconstructs splints to position the wrist, thumb, and fingers. In general, the therapist increases extension at only the wrist or fingers at one time to prevent the occurrence of flexion or extension deformities in the fingers.

The therapist may use other volar splints, such as the wrist support splint, with children who respond to control of wrist flexion but who do not need or cannot tolerate positioning of the fingers or thumb simultaneously. Wrist support splints allow the child to use the hand to perform functional activities, and the therapist may adjust them periodically to promote a progression of controlled finger extension during activities. The volar wrist splint should control ulnar deviation.

Controversy regarding the use of dorsal versus volar static splints is long-standing and has yet to be resolved. From a functional perspective, dorsal splints are most effective with children with muscle weakness or mild to moderately increased tone. The therapist uses the dorsal splint shown in Figure 10-25, A, on children with high tone and on those with low tone to hold the wrist in a neutral position. The splint provides support to the palmar arch. Although the child cannot use extreme wrist flexion, the therapist may use a small degree of wrist flexion in functional activities. Because no splint material contacts the volar surface of the hand and forearm, this splint interferes less with controlled arm use on a surface than a volar splint would. Children have responded favorably to this splint. However, dorsal static splints have limited use in controlling abnormal finger position in children with CNS deficits.

FIGURE 10-25 A, Dorsal splint to support the wrist in extension for stability or to control a mild to moderate pull into flexion. The hand section can be molded to support the palmar arch. B, Short opponens thumb splint made of a thermoplastic material. A similar design can be made with Neoplush. C, A Neoplush thumb splint is worn with orthokinetic cuffs on the forearm and upper arm. Both orthokinetic cuffs are designed to promote extension and inhibit flexion. The active area of the cuff on the forearm is over the wrist and finger extensors. The active area on the cuff on the upper arm is over the triceps.

The therapist uses thumb splints when a child has difficulty with thumb control but can adequately coordinate movements in other parts of the wrist and hand or when thumb control is the greatest problem. Exner and Bonder reported a study of short opponens thumb splint use with 12 children who had cerebral palsy with spastic hemiplegia.⁴⁹ These splints controlled the thumb over the first metacarpal joint and extended onto the distal phalanx (Figure 10-25, B). The researchers used the splints 8 hours daily for 6 weeks. After this program, two children showed improvement in bilateral hand use and three children showed improved grasp. Some children found that wearing the splints on the nonpreferred hand interfered with stabilization of materials that could not be grasped. In clinical use, the splint is beneficial in improving children’s functional use of their hands.

The therapist can use a soft splint to enhance thumb control in children with mildly increased tone. Neoprene and Neoplush are commonly used materials for soft splints. Use of the opponens splint pattern described previously is suitable when higher tone is present (Figure 10-25, B). The McKie splint (Figure 10-25, C) is a soft thumb splint designed specifically for use with children.⁹⁵ In a small study of four young children with cerebral palsy, this splint was found to have a positive effect on grasp and supination. The author noted that the children also showed improvement in use of the hand in play activities.

Gabriel and Duvall-Riley reported on the use of a weight-bearing splint for children who need additional wrist and/or finger-thumb support to allow for more effective weight bearing.⁵⁶ This splint is usually designed to extend from the forearm to the fingertips. It positions the child’s wrist in approximately 90° of wrist extension and the fingers in appropriate extension. The child wears this splint only during weight-bearing activities.

Other orthotic devices are available for children with increased tone or contractures. The positioning to prevent loss of range in children who have suffered head injuries is particularly important during extensive comatose, semicomatose, and recovery periods. The therapist uses inflatable air (pneumatic) splints⁷² to decrease tone, maintain and increase joint range, and stimulate somatosensory function.

Some therapists use casting with children who exhibit spasticity and contractures secondary to cerebral palsy or head injury.^71,^151,¹⁵² Casting may be used with children in an effort to enhance ROM and/or movement quality.¹³⁵ Tona and Schneck conducted a single-subject study using upper extremity casting.¹³⁸ Their findings were positive regarding the effectiveness of the approach for that child. Law et al. conducted a well-designed group experimental study to determine the effects of standard occupational therapy treatment on young children’s use of hand skills compared to an intervention program with upper extremity casting and intensive neurodevelopmental treatment.⁸⁶ The study was conducted over a 10-month period. The children in the study appeared to benefit as much from standard occupational therapy treatment as from the more intensive treatment coupled with casting. Casting of the arm and hand may be useful for decreasing tone, increasing ROM, or enhancing movement, but these changes may not result in improved occupational performance. Changes in these areas, as well as the changes in biomechanical areas, need to be assessed in research studies.

Teplicky, Law, and Russell emphasized the need for additional research on the question of hand splinting in children who have suffered a traumatic head injury as well as those with cerebral palsy.¹³⁵ In particular, they noted that although a number of studies have been reported in the literature, replication studies have not been conducted. Studies with groups of children and studies that replicate current findings are needed to support clinical decision making regarding splinting and casting in children.¹³⁵

REFERENCES

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8. Bayona, C.L., McDougall, J., Tucker, M., Nichols, M., Mandich, A. School-based occupational therapy for children with fine motor difficulties: Evaluating functional outcomes and fidelity of services. Physical & Occupational Therapy in Pediatrics. 2006;26(3):90–110.

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