OT 180: Evaluation Techniques in Occupational Therapy for Physical Dysfunctions July 16, 2009

Enrico C. Aguila, OTRP

 skills in moving and interacting with task, objects and environment
Posture • Stabilizes • Aligns • Positions Mobility • Walks • Reaches • Bends Coordination • Coordinates • Manipulates • Flows • • • • • Strength and Effort Moves Transports Lifts Calibrates Grips Energy • Endures • Paces

 Involve strength. and fastening clothing. and throwing a ball. lifting. and dexterity. . kicking.  Depend on both muscle tone and strength. Fine Motor Skills  Involve the small muscles of the body that enable such functions as writing. grasping small objects. fine motor control.Gross Motor Skills  Involve the large muscles of the body that enable such functions as walking. sitting upright.

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Mobility Negotiation of obstacles in the environment Exploration of environment Participation in sports activities and physical education GMS Play Social interaction Performance of ADL and IADL .

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• Consciousness . ability to discriminate. pain • range of motion. righting reactions. sensitivity to touch. muscle tone. supporting reactions. visual field. temperament and personality functions. postural alignment. perceptual functions. motor reflex functions . kinesthesia. mental functions of sequencing complex movement (motor planning) • visual acuity. strength. joint position sense. balance. sensitivity to pressure. tremors . energy and drive functions. endurance. mobility of bone functions.

Second Edition [TGMD-2] – Gross motor function measure (GMFM-66 & GMFM-88) – GMFCS . Second Edition [BOTMP-2] – Test of Gross Motor Development .Second Edition (PDMS-2) – Bruininks-Osteretsky Test of Motor Proficiency. Nonstandardized procedures – Interview – Observation  Standardized – Peabody Developmental Motor Scales .Expanded and Revised (2007) .

agility. negotiating obstacles or uneven ground  Ask for ability to ride a bike. playing with a ball  Play and functional tasks – Dressing. jumping. strength. and participation and interest in sports activities  Note for indicators of balance. reaching for and carrying objects. coordination and bilateral integration . running. climbing. endurance. ROM. playing on playground equipment. hopping. swim. engage in PE class. Ability to perform age-appropriate GMS – Walking. etc. skipping.

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– Fine Motor Quotient. Stationary. a composite of the Grasping and VisualMotor Integration subtests. . M. Locomotion and Object Manipulation subtests. a combination of the gross and motor subtests. Fewell (2000 Edition)  Ages: Birth through 5 years  Testing Time: 45-60 minutes  Test Type: Norm-Referenced  Scores include – Gross Motor Quotient which is a composite of the Reflexes. and – Total Quotient. Rhonda Folio and Rebecca R.

percentile ranks. Bruininks  Ages: 4 through 21 years  Testing Time: Complete Battery . Short Form 15-20 minutes  Scores/Interpretation: Age-based standard scores. Robert H. age equivalents for the Complete Battery only  8 subtests  5 composite scores . and stanines.45-60 minutes. Bruininks and Brett D.

.7 items (e. tapping foot and finger. cutting out a circle.. Fine Motor Integration .7 items (e. Manual Dexterity . Bilateral Coordination . connecting dots) 2.1. one-legged side hop) 7.8 items (e.g. Upper-Limb Coordination .g. copying a square) 3. Balance . standing long jump.5 items (e.9 items (e.g..g. copying a star.g.5 items (e.7 items (e. catching a tossed ball) 8. shuttle run.5 items (e. walking forward on a line... Running Speed and Agility .. transferring pennies. Strength .g.. sorting cards. stringing blocks) 4.. jumping jacks) 5. standing on one leg on a balance beam) 6.g. sit-ups) .g. throwing a ball at a target. Fine Motor Precision .

 BOT-2 provides a separate measure of gross and fine motor skills. making it possible to obtain meaningful comparisons of performance in two areas – Fine Manual Control – Manual Coordination – Body Coordination – Strength and Agility – Total Motor Composite .

Ulrich  Ages: 3 through 10  Norm-referenced  12 skills (six for each subtest): – Locomotor: run. horizontal jump. Dale A. slide. – Object Control: striking a stationary ball. hop. . gallop. leap. underhand roll. stationary dribble. kick. catch. overhand throw.

 Dianne J. Peter L. DS)  2 versions: – GMFM-88 – GMFM-66 . Russel. Rosenbaum. Avery. Lisa M. Mary Lane  Clinical measure designed to evaluate change in GMS (CP.

. GMFCS . walking. and wheeled mobility.Expanded and Revised (2007)  5 level classification system that describes the gross motor function of children and youth with cerebral palsy on the basis of their selfinitiated movement with particular emphasis on sitting.

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reaching. Righting reactions  Equilibrium reactions  Protective reactions  Balance skills  Head control  Trunk control  Pelvic control  Anticipatory postural control – catching. throwing .

 Supine  Prone  Prone on elbows  Quadruped  Kneeling  Standing .

 Crawling  Creeping  Walking  Running  Jumping  Going up and down the stairs .

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(Exner. Effective use of hands to engage in a variety occupations depends on a complex interaction of hands skills. 2005) . and visual perception. cognition. postural mechanisms.

usually the hand muscles.   Fine Motor Coordination requires small. such as the opposing thumb-to-fingers position that is required to hold a pen Reach extension and movement of the arm for grasping or placing objects Grasp attainment of an object with the hand . discrete. specialized muscles to function together.

 Carry transportation of a hand-held object from one place to another. also referred to as “moves” and “lifts” (AOTA. 2002)  Voluntary release intentional letting go of a hand-held object at a specific time and place  In-hand manipulation adjustment of an object in the hand after grasp .

serves as an extension of the limbs and enhance the efficiency with which skills are performed  Midrange control  Midline crossing  Isolated finger control  Dexterity . Bilateral hand use use of two hands together to accomplish an activity  Tool a device for working on something.

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Visual Skills     plays a major role in the development of hand skills in children especially in learning new motor skills 4 months: infants begin to move their hands under visual control as they reach fro an object and make differentiated finger movements 6 months: visuomotor development required for accurate reach is achieved 9 months: infant guides his or her hand movements using visual somatosensory integration .

5 years old: child can identify common objects by touch alone  5 years old: good haptic recognition of unfamiliar objects  6 years old: identification of common objects and perception of spatial orientation are well developed . important in isolated movements of the fingers and thumb movements  6 months: able to match haptic perception (knowledge of objects gathered by means of active touch) of some 3D objects with visual perception  2.

poor tactile discrimination and dyspraxia . important factors to consider: sensory registration. tactile hypersentivity.

 6 months: infant uses visual and tactile stimuli to guide fine motor development and begins to develop awareness of object placement in space  Between 6-12 months: object learning is encouraged .

 9-10 months: infants adapt their arm positions to horizontal versus vertical object presentations and shape their hands appropriately for convex and concave objects  2 years old: relate objects with one another with more accuracy and purpose .

LOM. Functions of Joints and Bones – hand integrity is important for hand function – consider the following: missing one or more digits. muscle weakness and joint inflammation .

Muscle Functions
– includes muscle power (strength), muscle tone and muscle endurance – strength is needed to initiate all types of grasp patterns and maintain these patterns during lifting and carrying – tone is needed for stability of the parts of the arms and hands during activities and the types of movements possible

 Reach  Grasp Patterns  In-Hand Manipulations  Carry  Voluntary Release  Bilateral Hand Use
 Tool Use

Reaching with an extended arm starts at 1222 weeks of age; the objects are rarely grasped and then only by accident Midline orientation develops with the hands initially close to the body; unilateral reaching occurs when there is increasing dissociation of the two body sides; hands opens in preparation for grasping the object (usually, the hand is more open than necessary for the size of the object)

Mature reach is seen with sustained trunk extension and a slight rotation of the trunk toward the object of interest Over the next few years. reaching skills become refined with increasing accuracy of arm placement and the grading of finger extension as appropriate to the size of the object Optimal hand opening for the object size at the initiation of reach is achieved at age 12. .

According to Napier According to Weiss and Flat According to Erdhardt Prehension Developmental Assessment (EDPA) .

the thumb is held flexed or abducted to other fingers .it is the grasp of an object – – Precision grasp – opposition of the thumb and fingertips Power grasp – use of the entire hand.  Non-prehensile .pushing or lifting an object with the fingers or the entire hand Prehensile .

transverse metacarpal arch is flat. there is partial thumb adduction.Grasp with no thumb opposition – Hook Grasp – used to carry objects. thumb can be flexed over the fingers (if additional power is needed) Ex: Holding a handle – Power Grasp – used to control tools or other objects. pad of thumb is placed against the radial side of the index finger at or near the distal DIP joint Ex: using a key . fingers are adducted with flexion at the IP joints and flexion and extension occurs at the MCP joints. it is the flexion of the ulnar fingers and less flexion with the radial fingers and thumb extension and adduction Ex: brushing hair – Lateral Grasp – used to exert power on or with a small object. MCP flexion and slight IP flexion.

forming a circle. all joints of the index finger and thumb are partly flexed. control of this grasp suggests the child’s ability to dissociate the two sides of the hand and to use tips of the index finger and thumb Ex: Picking up small beads – Palmar pinch • Standard pad to pad or two-point pinch or pincer grasp three-point pinch or three-jaw chuck pattern . Grasp with thumb opposition – Tip pinch – opposition of the thumb tip and the tip of the index finger.

Throwing a ball – Cylindrical – transverse arch is flattened to allow the fingers to hold against the object. for additional force. control of this grasp suggests the child’s ability to balance control of the intrinsic and extrinsic hand muscles Ex.– Spherical – there is wrist extension. fingers are slightly abducted and IP and MCP joint flexion is graded according to the size of the object. Opening a jar . hypothenar eminence assists the cupping of the hand for control of the object . requires the stability of the longitudinal arch to grasp large objects. palmar surface of the hand contacts the object more Ex. finger abduction and some degree of flexion at the MCP and IP joints.

hyperextension of the MCP joints and flexion of the IP joints are evident. wrist is more flexed when objects are larger and only the pads of the fingers contact the object. Holding a CD . Disk – finger abduction is graded according to the size of the object. thumb extension also increases with object size Ex.

Between ventral thumb and index. Between fingertips or fingernails. adduction and flexion of thumb and flex or partially extended fingers Scissors grasp. Between thumb and side of curled index finger Inferior pincer grasp. beginning of thumb opposition Pincer grasp.A. but gives visual attention Raking and contacting object Inferior-scissors grasp. Grasp of Pellet Age Natal 3 months 6 months 7 months 8 months 9 months 10 months 12 months Skill No grasp or visual attention No attempt to grasp. thumb opposed Fine pincer. Between distal pads of thumb and index. thumb joint flexed . Rake into palm.

wrist flex Primitive squeeze grasp/crude palmar grasp. transfer cube from one hand to another hand Radial-digital grasp. Object squeezed against other hand or body Palmar grasp. Opposition of thumb and fingertips.B. wrist straight 7 months 8 months 9 months . Fingers on top of object press it into center palm. Fingers on far side of object press it against opposed thumb and thumb side of palm Radial palmar grasp with wrist straight. space visible between Radial-digital. thumb adducted Radial-palmar grasp. may swipe object. Grasp of Cube Age Neonate 3 months 4 months 5 months 6 months Skill Visual attention. grasp upon contact of little finger side. palmar reflex grasp Visual attention.

palmar grasp. use of intrinsic muscles with extrinsic muscles (long flexors and extensors) . finger pad contact – Use of long finger flexors. radial grasp – Palmar contact.– Ulnar grasp. finger surface contact.

  requires control of the arches of the palm includes translation. shift and rotation .

      Wrist stability Opposed grasp with thumb opposition and object contact with the finger surface (not in the palm Isolated thumb and radial finger movement Control of the transverse metacarpal arch Dissociation of the radial and ulnar sides of the hand Successive increases and decreases in fingertip forces .

an object is held by the pad of one or more fingers and the pad of the thumb and moved into the palm proximal to the metacarpal-phalangeal joints Ex.Finger to palm translation . Putting a coin inside a coinbank . Picking up a coin Palm to finger translation .an object is moved from some area of the palm out to the distal finger surface Ex.

Unscrewing a bottle cap . Inserting thread through a bead Simple rotation .occurs when an object is turned or rolled between the pads of the fingers and the pad of the thumb via an alternation between thumb movement and finger movement Ex.movement occurring at the finger and thumb pads with alternation of thumb and (usually radial) finger movement Ex.Shifting .

several objects held in hand. Turning a pencil to use an eraser In-hand with stabilization .Complex rotation –fingers and thumb alternate in producing the movement and the fingers move independently of one another Ex. manipulating an object in one hand and stabilizing others .

 involves a smooth combination of body movements accompanied by stabilization of an object in the hand child must be able to hold the forearm stable while in any degree of rotation and movement and must be able to modify the forearm and wrist positions to achieve optimal position  .

then object pulled out of one hand by the other hand. refinement up to age 4 with graded release Components: – – Replacement Release . release by full arm extension. by 9 months.Initially involuntary dropping.

710 Press down on months grasp reflex months surface to release strong months Involuntary Mutual fingering in midline Transfer from hand to hand 1-4 8 months 9-10 months Above surface with wrist flexion Into container with wrist straight small 4 months 4-8 (7)mont hs 10-14 months Clumsy into container 5-6 6-7 7-9 months months months 2-stage transfer 1-stage transfer Volitional release 12-15 months 18 months Precise. controlled with wrist straight Raisin dumping into small container .Age 0-1 Skill Age Skill No release.

– Asymmetric movements prevail until 3 months – Symmetric movements emerge until 10 months • Types: – Symmetrical – Asymmetrical – Reciprocal .

Age Skill 12-18 Use of both hands for different months functions 18-24 Manipulation skills emerge months 2.5 years Use of two different hands for old very 2 different functions .

goal-directed form of complex object manipulation that involves the manipulation of the tool to change the position. condition or action of another object tools enhance the proficiency with which skills are preformed and are needed for feeding. writing. grooming. cutting and a variety of other tasks basic to activities of daily living.  . is a purposeful.

Mature Grasp Isolates middle finger and thumb for insertion into scissor loops Stabilizes lower loop with the index finger Rests the scissor loops near the bent middle joints of the fingers Ulnar fingers flexed Usually achieved at age 6 Immature Grasp No fingers in loops Two hand approach Index and middle fingers in loops Scissor loops to close o knuckles .

flower.5 – 5 years old 5 years old 6 years old .Age 1-1. tree.5 year/s old 2 years old Skill Shows interest in scissors Snips with scissors Snipping is closing the scissors on the paper with no movement of the paper and with no ability to repetitively open and close the scissors.5 years old 3. Cuts across a 6-inch piece of paper Cuts across a 6-inch line Cuts a 5-inch circle with ½ inch limits.5 -4 years old 4. cuts 5-inch triangle with ½ inch limits Cuts square Cuts zigzag lines and curves Cuts out items such as house.5 years old 3-3. sun 2.

wrist straight old .5 year s old 2-3 Grasp Palmar supinate grasp .held with fisted hand .wrist slightly flexed .Age 1-1.forearm moves as a unit .arm moves as a unit Digital pronate year .wrist slightly supinated away from mid-position .wrist pronated .held with fingers s .wrist ulnarly deviated .wrist slightly flexed .

grasped distally .Dynamic Quadrupod .MCP joints stabilized during fine.Lateral tripod .no fine localized movement of digit component.ring and little fingers flexed to form stable arch . hand moves as a unit Dynamic tripod .grasped proximally .wrist slightly extended . index and middle fingers .continual adjustments by other hand .Lateral Quadrupod 4. index and middle fingers .held with precise opposition of distal phalanges of thumb.ring and little fingers only slightly flexed . localized movements of PIP Other grasps: .3.5 -6 years old .5 – 4 years old Static tripod .held with crude approximation of thumb.

5 years old 2 years old 2.5 years old 3 years old 3.5 years old 5 years 6 years old 7 years old .Developmental Stage Age 1 year Skill Imitative scribble Mouth crayons Bangs crayon on paper Incipient imitative scribble Spontaneous scribble Imitates vertical stroke Imitates circular stroke Imitates horizontal stroke Imitates 2 or more strokes for cross Copies circle Imitates cross Traces diamond with rounded angles Copies cross Copies square Traces cross Copies triangle Copies diamond Print ABC.5 years old 4 years old 4. uses pencil eraser Copies vertical diamond 1 ¼ years old 1.

Age Skill 2-4 Hand preference years old 5-6 Hand dominance established years old 7 and up Handedness .

  – – – – Conduct a screening Conduct a formal hand skills evaluation Measurement of active and passive ROM Evaluation of strength Evaluation of tactile and proprioceptive functioning Assessment of postural alignment and postural stability .

– Administration of standardized general developmental test – Administration of a developmental motor test – Administration of standardized test of fine motor skills for older children and adolescents – Administration of visual-motor integration test – Assessment of hand skills in prevocational or work task .

Prerequisite skills: Small muscle development Eye-hand coordination Ability to hold utensils or writing tools Capacity to form basic strokes smoothly Letter perception such as ability to recognize forms. notice of likeness and differences Orientation to printed language .

letters.Domains of handwriting  writing the alphabet in both uppercase and lowercase letters along with numbers  copying is the capacity to reproduce numerals. either manuscript to manuscript or cursive to cursive  near-point copying is producing letters or words from a nearby model  far-point copying is copying from a distant vertical model to the writing surface  transition from manuscript to cursive  dictation  composition is the generation of a sentence or paragraph by the child . and words from a similar model.

placement of text on and within the writing guidelines .it is starting from the correct starting point alignment .letter formation .it is the leading in and leading out of letters.also called baseline orientation . includes rounding of letters and closure of letters .

 spacing – dispersion of letters within words and words within sentences – includes text organization on the entire sheet of paper  size – this refers to the letter relative to the writing guidelines and to the other letters  slant – angle of the text must be consistent or uniformed .

 Writing speed – number of letters written per minute  Ergonomic factors – includes writing posture. upper extremity stability and mobility and pencil grip – writing posture: does the child rest his or her head on the forearm or desktop when writing? Is the child falling and spilling out of his or her chair? Does the child stand behind the desk or kneel on the chair? Are the desktop and chair at suitable height? .

wrist to allow the dexterous hand to manipulate the writing instrument.– stability and mobility of the upper extremities refer to the stabilization of the shoulder girdle. – Grasp: Poor writers tend to demonstrate a greater variety of atypical grasp patterns. . elbow.

Examining written work samples Discussing the child’s performance with the parent. teacher and other team members Reviewing the child’s educational and clinical records Directly observing the child when he or she is writing in the natural setting Evaluating the child’s actual performance of handwriting Assessing any suspected performance skills interfering with handwriting .

 PDMS-2  BOTMP-2  EDPA .

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