Hand function

❖ Hands are the "tools" most often used to accomplish work, to play, and to perform

self maintenance tasks.

❖ Hand function is a complex interaction of hand skills, postural mechanisms,

cognition, and visual perception.
❖ Hand skills are critical to interaction with the environment. They are those patterns
that normally rely on both tactile proprioceptive and visual information for
accuracy. The patterns include basic reach, grasp, carry, release, and the more
complex skills of in-hand manipulation and bilateral hand use.
Brief definitions of these patterns:
• Reach: Movement and stabilization of the arm and hand for the purpose of contacting an
object with the hand.
• Grasp: Attainment of an object with the hand.
• Carry: The movement of the arm in space for purpose of transporting a hand – held
object from one place to another.
• Release: The intentional letting go of a hand – held object at a specific time and place.
• In-hand manipulation: The adjustment of an object within the hand after grasp.
• Bilateral hand use: The effective use of two hands together to accomplish and activity.
The term hand skills may be used interchangeably with the term fine motor coordination
or fine motor skills.
Sequence of development of hand skills:
1- Reaching:
The random are movements of the newborn are asymmetric and the object is rarely
grasped, and then only by accident. Gradually a midline orientation of the hands develops as
the child holds the hands further away to view them. This pattern precedes the onset of
symmetric bilateral reaching, usually first in supine then in sitting. As the baby shows
increasing dissociation of the two body sides during movement, unilateral reaching begins.

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 All activities are done with pronated forearm till active supination develops at 12 months of
age. Mature reaching is usually seen in conjunction with sustained trunk extension and a
slight rotation of the trunk toward the object of interest.
2- Grasping:
Classification of grasp patterns
• There are two basic term to describe hand movements:
- Non-prehensile movements: involve pushing or lifting the object with the fingers or
the entire hand.
- Prehensile movements: involve grasp of an object and may be further divided into
precision or power.
o Precision grasp: is characterized by opposition of the thumb to fingertips to hold
an object.
o Power grasp: involves the entire hand and are used to resist forces on the object
being held.
3- In- hand manipulation:
There are three basic categories of hand – manipulation.
o Translation: is the linear movement of object from palm to fingers and/or fingers to palm.
o Shift: is the linear movement of object between and among fingers e.g., buttoning,
putting laces via the holes on shoes adjustment pen after grasp for writing.
o Rotation: is the movement of an object around one or more of its axes. It involves the
turning or rolling of an object held at the finger pads approximately 90° or less e.g.
unscrew a small bottle cap.
4- Carry:
It involves a smooth combination of body movements while stabilizing an object in the
hand. Co contraction often occurs in the more distal joints of the wrist and hand while the
forearm must be able to held stable in all positions.
5- Voluntary Release:
It is like grasp, depends on control of arm movements. Development of smooth, accurate
release of small objects normally takes several years.

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6- Bilateral hand use:
Asymmetric movements of the arms occur up to three months. Symmetric patterns appear
between 3 to 10 months, when bilateral reach, grasp, and mouthing of the hands and objects.
More complex bilateral symmetric skills, such as catching or bouncing a large ball develop
later in childhood.

▪ Causes of the problems in the development of hand function:

1- Muscle tone disorders.
2- Presence of primitive reflexes (ie. Grasp reflex, ASTNR).
3- Abnormal co-ordination of muscle function.
4- Musculoskeletal abnormalities.
5- Cognitive and/or perceptual disorders.

Evaluation of hand skills in children:

When a functional problem with a daily life skill is identified, the therapist needs to
continue the data- gathering process to determine if it is reasonable to carry out a full evaluation
of fine motor performance. This information needs to include data about the child's age, gross
and fine motor functioning, cognitive and perceptual skills, social situation and emotional
development.

Evaluation content:
• Muscle tone assessment of upper limb.
• Measurement of active and passive range of motion.
• Evaluation of strength (muscle testing / Grip and pinch strength test).
• Assessment of tactile and proprioceptive functioning.
• Screening for fine motor skills through administration of developmental motor test.
For example: Peabody developmental motor scale.

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Treatment (Guidelines for intervention)
Goals
The child functional problems, number and types of the problems the hand skill area and
the developmental sequences of skills, affect the selection of goals. But, child with motor
disabilities, other factors affect the goals setting and the strategies selected for intervention.
These factors include the type of functional skills the child needs.
Sequencing treatment sessions:
Direct treatment to improve hand and arm function should be carried out in the following
sequence:
a- Preparation:
1- Positioning of the child.
2- Inhibition or facilitation of tone.
3- Activities to improve postural control (head, trunk, shoulder).
b- Hand skill development:
1. Activities that emphasize isolated arm and hand movement such as supination and wrist
extension.
2. Reach, grasp, carry and release activities.
3. Isolated finger movement activities.
4. In-hand manipulation activities.
5. Bilateral hand use activities.
c- Generalizing skills:
❑ Integration of hand skills into functional activities.

d- Splinting for children:

Splinting is often a component of occupational therapy intervention for children with hand
function problems.

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A- Preparation for hand skill development:
Many children require preparation of the total body in each treatment session before
0intervention for specific hand skill problems are addressed. In addition to intervention to
improve motor function, visual awareness of the hands in conjunction with tactile and
proprioceptive input should also be encouraged.
1- Positioning of the child:
In selecting positioning of the therapist and the child for fine motor intervention, the
therapist must consider the position that is most optimal for eliciting the particular skills desired
in that child and the position in which the child will use the skills. Certain body positions can be
used more effectively in treatment of some hand skills than others.

❖ Supine is an effective position for working with young children on arm movements and
visual regard of the hands during movement.

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❖ Prone on forearms is an appropriate position for addressing shoulder stability and co-
contraction in 90 degrees of elbow flexion, gross bilateral manipulation of objects and
visual regard of the hands.

❖ Side lying can be an effective position for encouraging unilateral arm movement to bat at
object and for hand – to- hand play.
❖ Sitting at a table is often the position in which children are most likely to use fine motor
skills. For children who are not yet independent in sitting, lateral supports and chest straps
are used to achieve stability in sitting.

A table surface should be a work surface rather than a support surface. The table or tray should
be only slightly above elbow height, because a lower table promotes use of body flexion and a
higher surface promotes use of abduction and internal rotation
of the arms.

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❖ Standing may be appropriate position for treatment of hand skills for children with mild to
moderate motor involvement. Many daily living skills are done while standing, such as
brushing teeth, buttoning clothing, shaving, cooking. Standing should be used only after
the child has mastered the skills in a sitting position.

2- Managing tone:
❑ Modulation of the tone throughout the body should be carried out before participation in
hand skill activities.
❑ The child with increased tone throughout the body may need overall inhibition of tone
before participating in hand skill activities.

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 ❑ Slow rotary movements using small ranges of motion between internal and external
shoulder rotation and between forearm pronation and supination can help inhibit tone.
3- Improving postural control:
Upper extremity weight bearing is useful as a treatment technique for improving postural
control and improving stability in the scapulo humeral area. Proprioceptive input is provided
during weight- bearing activities. These can be carried out with the child in prone on
forearm, prone on extended arms, side-sitting, or long- sitting, depending on the child's skill
level.

B- Hand skill development:

1- Isolated movement control:
The therapist may choose to address specific movements in the upper extremity in
isolation of specific hand skills. For example., the therapist may assist the child in using
elbow flexion- extension or supination – pronation or wrist flexion – extension movement
before integration these movements into reaching, grasping, or release patterns.

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2- Reach:
Typical problems in reach include the following:
1. Use of shoulder abduction and internal rotation to initiate reach.
2. Use of shoulder elevation and lateral trunk flexion to increase the height of arm for
reaching.
3. Difficulty to maintain an upright body posture when reaching forward or across midline.

Treatment suggestions for reaching:

1. Maintain visual regard of the object while contacting the object with the hand.
2. Contact objects in various planes.
3. Sustain some degree of finger extension while reaching for objects in various planes.
4. Reach with both hands together for an object presented at midline.
5. Orient the forearm appropriately for object contact during bilateral reaching.
6. Reach with 45 degrees of shoulder flexion, using neutral rotation of the humerus and
elbow extension.
7. Reach with 90 degrees of shoulder flexion using slight external rotation of humerus,
elbow extension and forearm supination to mid position.
8. Reach across midline with an erect trunk posture and humeral external rotation,
elbow extension and forearm supination to mid position.
9. Reach above the head with control.

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3- Grasp:
The following problems have been observed in development of effective grasp:
1. Fisting or finger flexion that prevents hand opening.
2. Wrist flexion (often with ulnar deviation) in combination with finger extension.
3. Sustained forearm pronation, which interferes with use of radial finger grasp patterns.
4. Thumb adduction, often with MCP or IP flexion.
5. The lack of the ability to initiate or sustain thumb opposition.
6. Inability to use grasp patterns that involve control of the intrinsic finger muscles.
7. Inability to vary grasp in accordance with object characteristic

Fisting or finger flexion Wrist flexion in combination with finger

extension.

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 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.

Treatment suggestions for grasping:

1. Use a sustained palmar grasp with the arm in a variety of positions.

2. Use finger surface grasp on a variety of objects (rather than using a palmar grasp).

3. Use a finger pad grasp with thumb opposition and one, two, or three fingers on objects
that are small or have a small diameter.
4. Vary the type of opposed grasp pattern used in accordance with object shapes and
characteristics.
5. Use an effective lateral pinch grasp pattern.
6. Use a grasp with MCP flexion and IP extension to hold thin, flat objects.
7. Use a power grasp on a variety of tools in daily living tasks.
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4- Voluntary release:
Children with difficulty in releasing objects may have the following problems:
1. Fisting of hand and tight finger flexors.
2. Difficulty with sustained arm position during object placement and release.
3. Difficulty combining wrist extension with finger extension.
4. Inability to use slight forearm supination to allow for release in small areas or near
other objects and with visual monitoring of the placement.
5. Overextension of the fingers in release, limiting control of specific object placement.
Treatment suggestions for voluntary release:
1. Release objects into a container placed on the floor.
2. Release objects into a container placed on a table surface with the container at
arms length from the child's body to encourage wrist extension with finger
extension.
3. Stack three (or more, up to 10 to 12) 1-inch cubes.
4. Release tiny objects into a container with a small opening.
5. Place objects within 1 inch of other objects without making other objects move
or fall.
6. Release unstable light weight objects while keeping them in an upright position.

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5- In – hand manipulation:
Problems that limit in – hand manipulation include the following:
1. Limited finger isolation and control.
2. Inability to effectively cup the hand to hold objects in the palm.
3. Inability to hold more than one object in the hand at the same time.
4. Insufficient stability to control object movement at the finger pads, thus objects
are dropped frequently.

Treatment suggestions for in-hand manipulation:

1. Use the skill of finger to palm translation to hold a coin in the palm of the hand.
2. Use finger – to – palm translation with stabilization skills to hold several coins
in one hand.
3. Use shift skills to adjust a spoon knife or fork for appropriate use.
4. Use simple rotation skills in rotating a pen to put the top on.
5. Use complex rotation skills in holding a key ring with keys, rotating the correct
one for placement in the lock.

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6- Bilateral hand use:
Lack of bilateral hand use as in children with hemiplegia or brachial plexus injuries, can
cause children to approach all tasks in a one – handed manner. Other problems include the
following:
1. The child cannot effectively sustain both hands at midline.
2. The child has difficulty using supination during bilateral activities.
3. The child has associated reactions in one upper limb when using the other.
4.
Treatment suggestions for bilateral hand use:
1. Bring both hands to midline for grasp of a medium or large – sized object.
2. Use both hands together to push large objects.
3. Use both hands together to lift and carry large objects.
4. Stabilize materials on a table surface with one open hand while the other hand
manipulates materials (e.g. coloring, writing).
5. Stabilize materials using a variety of grasp pattern while the other hand manipulates
materials (e.g., holding a cup while pouring liquid into it, stringing beads).

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c- Generalizing skills:
Activities must be presented to the child in a meaningful context. For example,
reaching can be carried out during dressing. Grasp can be incorporated into independent
eating; voluntary release can be structured into a game that uses movable pieces.
Many other possible combinations help the child to develop mature function of hand or
arm skills in conjunction with increasing competence in daily life activities.
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d- Splinting for children:
Splinting is often a component of occupational therapy intervention for children with hand
function problems.
Problems that indicate the usage of splints:
A. Deformities.
B. Sustained abnormal posturing.
C. Increased tone.
D. Limited movement of the hand.

Precautions 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

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Types of splint used with children
splints may be divided into those that allow hand movement and those that don't.
❖ Static splints: Maintain the joint in a static position e.g. cock up splint, thumb
positioning splint.

cock up splint
❖ Dynamic splints: Assist the child with a particular wrist, finger, or thumb
movement.

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