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Finger and Hand Fitness for School Based Occupational Therapists

Naomi Aaronson MA, OTR/L, CHT pilatesot@gmail.com

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The opinions expressed in this webinar are solely those only of the author, and do not represent any other entity or agency, city, department, district, or school. The exercises provided are suggestions and are not a prescription. These exercises should be performed under the guidance of a medical professional.

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Disclaimer

Discuss the Common Core and its impact upon school based practice

Review hand anatomy and the importance of understanding it’s role in hand function for children

Highlight recent research on pencil grip as well as norms for pinch/ grip

Explore hand exercises and activities that can help our kids meet these new demands

Discuss other aspects of hand function including in hand manipulation

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Through power point presentation, discussion, and videos, we will achieve the following

goals:

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School demands have significantly changed

Children must write more for longer periods of time

Children engage less in activities such as play dough, arts and crafts, cutting, and coloring which develop their fine motor skills and grip/pinch strength

Children have less gym and physical activities than before, so have weaker cores and scapula stability

Why is hand and finger fitness important?

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Common Core is evidence based and research based guidelines for school standards

Improvement upon state standards

Consistency across states

Single set of clear educational standards for K-12 th grade in English and mathematics that demands high expectations

Promotes equity and high demands for school performance

Adopted by 45 states, DC, and 4 territories

The goal is to prepare students for the future , whether it be achieving success in a career or in college

What is the Common Core?

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Many of us involved in school based OT focus on handwriting for ensuring success in the classroom

Handwriting builds a sold foundation for achievement

Research shows that handwriting is a foundational skill that can influence a students reading, writing, language use, and critical thinking

Saperstein Associates (2012)

How does this relate to School Based Occupational Therapy?

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Handwriting impacts the developing brain

MRI scans reveal that after letter instruction neural activity was more enhanced and adult like than those children who simply looked at the letters (Bounds, 2010)

Children are required to write on paper for 25 to 60% of their classroom learning time in K-5

Research states that learning how to write by hand is a necessary motor exercise as it develops eye hand coordination

How does this relate to school based OT?

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Studies have estimated that between 10-30% of children struggle with handwriting

Dysgraphia: When a child has handwriting difficulties

Characterized by difficulty in production of legible writing and maintaining the quality and speed of writing

This effects classroom performance and self esteem, as children may avoid writing

This webinar is not about handwriting per se but about the implications of the Common Core and how we can help kids meet these increased demands with another focus

How does this relate to Occupational Therapy?

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CC: Students should demonstrate increased sophistication in language use, organization, as well as addressing content

Goal: The main goal for writing is to produce and publish writing pieces as well as develop and strengthen writing by planning, revising, editing, and rewriting. This is a long process.

The kids we see in OT struggle just to form the letters, hold pencils, use manipulatives and school based tools such as scissors, rulers, and compasses, organize their thoughts, and have the necessary strength and endurance to perform these tasks daily and weekly.

Back to the Common CoreWhat are the expectations?

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CC Kindergarten Use a combination of drawing, dictating and writing to narrate a single event

HWT- Use a correct and efficient grasp for writing

Stabilize paper with non writing hand while drawing/ writing Position writing paper correctly Maintain sitting posture Write simple 2-3 word sentences

Expectations: 11/13 2-3 short sentences 4/15 4-5 sentences What do we see in reality? Kids who cannot sit for long periods of time, hold pencils or

scissors , do not know how to form letters correctly and fluidly, as well as struggling with fine motor issues

Literacy Expectations - Kindergarten

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CC First grade

Focus on a topic and add details to strengthen writing, create opinion pieces

HWT

Write 2-5 word sentences . Write a short paragraph

Expectations: 11/13 4-5 sentences as well as paragraphs of varying lengths 4/15 2- paragraphs of 4-5 sentences

What do we see? Kids still struggling to form letters correctly, hold pencils, write for longer periods of time, having difficulty organizing and learning to read

Literacy Expectations 1st Grade

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CC: Participate in shared research and writing, use of a variety of digital tools to

produce and publish writing by revising and editing HWT Write sentences with 2-8 words Write paragraphs using proper conventions Write 3-5 sentence paragraphs Write friendly letters Expectations: 11/13 2 paragraphs of 3-5 sentences or more 4/15 4 paragraphs of

4-5 sentence length What do we see? Kids who cannot keep up with the speed, kids with decreased

in hand manipulation, poor wrist and hand strength so endurance is a concern as well as kids who have difficulty organizing their thoughts onto paper and write .

Literacy Expectations – 2nd Grade

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CC-

Write routinely over extended time frames and shorter time frames , write opinion pieces , use linking words , write narratives, develop and strengthen writing by planning, revising and editing

HWT

Begin cursive - has anyone seen that lately?

Write 5-6 sentence paragraphs by combining sentences to express ideas or opinions

Friendly letters

Expectations: 11/13 4-5 paragraphs with 5-6 sentences each 4/15 6 paragraphs of 4-5 sentence length

What do we see? Kids that are stressed out over testing, kids who express pain after writing for long periods of time.

Wrist and hand strength is integral to write over extended time frames and to have the necessary endurance and speed to keep up with classmates. We may need to explore other related factors such as fatigue, in hand manipulation, grip strength and speed. It is important to remain abreast of classroom written output requirements to meet children’s needs during OT

Literacy Expectations 3rd Grade

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It is always good to review anatomy and refresh how our bodies work. We can then begin to examine why they don’t work the way they should and determine what muscles are involved

Hand therapy exercises have a role in school based practice

Understanding anatomy will help you better plan goal oriented activities to meet children’s needs for increased output- production and endurance

Time to review hand anatomyWhy is this important ?

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The muscles in the hand need to work together synergistically.

Wrist muscles are important because they stabilize the hand.

We need to understand the hand and wrist to be able to intervene appropriately when children are unable to perform in the classroom due to delayed developmental or poor grip/pinch patterns.

Relevant Hand and Finger Anatomy

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Finger movements work with a stable wrist When the wrist is flexed, ones grip is weaker. How many

of the kids that we work with have flexed wrists when cutting or writing?

Wrist extension is critical to allow fingers to have the best mechanical advantage. Flexors create grip while the wrist extensors stabilize

Wrist flexors need to work with wrist extensors to co- contract and provide the best functional position.

Wrist extensors and flexors

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Superficial: PT, FCR (very strong flexor and radial deviator), PL ( assists in palmar arching ,flexes the wrist), FCU ( flexes wrist and ulnar deviates)

Start at medial epicondyle (outside of the hand) Intermediate: FDS> all fingers (flexes MPs and PIPs) inserts at PIP jts. Works

with the wrist flexors regardless of wrist position Deep: FDP (flexes DIP jts of 4 fingers, flexes MP<PIP< and DIPs by continued

action) Works optimally with the wrist in extension FPL, PQ Did you know that the finger flexors are 62% stronger than the extensors? Li, Z ., Zatsiorsky, V. et al. The Effect of Finger Extensor Mechanism on the

flexor force during isometric tasks? Journal of Biomechanics 2001 ;34: 1097

Extrinsic Wrist and hand flexors

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Superficial: BR, ECRL, ECRB (extends wrist ,radial deviation, stabilizes wrist for power), EDM, ECU (works with thumb triad , extends wrist and ulnar deviation, stabilizes wrist for skill) and anconeus

Deep: Supinator, APL, EPB, EPL, EIP (extends MP of index finger and wrist)EDM( extends MP jt. Of pinky) EDC (extends MP jts. Of digits 2,3,4,5)

Starts at lateral epicondyle (outside of the hand)

Extrinsic Wrist and Finger Extensors

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Thenar – fleshy area at base of thumb

OAF muscles

OP largest , opposes ,rotates CMC jt. Opposer of thumb

Origin: tubercule of trapezium/ Insertion lateral margin of thumb metacarpal

Necessary for holding a pencil, scissors

APB- Abducts thumb

Origin: tubercule of scaphoid and trapezium /insertion lat side of proximal phalanx

FBP- Flexes MP jt. Rotates the thumb for opposition

Origin: Tubercule of Trapezium/ Insertion base of thumb proximal phalanx

*****They open web space ,pronate thumb, position the thumb for distal manipulation

Thumb intrinsics are the stronger group

What about the intrinsic thumb muscles? Responsible for fine

movements of the thumb

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Extrinsic Muscles - EPB –extends thumb MP , EPL extends IP jt. of thumb and radially deviates the wrist

APL abducts the CMC in plane of palm, radially deviates the wrist, and slight flexion

FPL flexes the wrist ,flexes the IP jt. of thumb (used in pinch)

Intrinsic thumb muscles APB, FPB, OP- necessary for thumb rotation at the CMC for opposition, manipulation and delicate touch (skilled muscles)

AP- Power muscle and adds strength to opposition Children use this muscle when their thumb/wrist muscles

are not strong. We naturally go to the strongest muscle during functional tasks rather than using a weaker muscle.

Thumb- Cause of many problems in school aged children

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Located medial side of palm ODM –Lies deep to other hypo-thenar muscles, produces

opposition Origin: Hook of hamate Insertion-Medial margin of 5th

metacarpal ADM – Most superficial, Abducts little finger Origin: Pisiform and tendon FCU Insertion: Base of

proximal phalanx little finger FDM- lateral to ADM Origin: Hook of hamate Insertion: Base of proximal

phalanx of little finger

What about the hypo-thenarmuscles?

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Interossei means between bones most specifically the metacarpals PADS- 3 Palmar Interossei . Stabilize MP joints and shape fingers to

fit objects Responsible for adduction of index, ring and little fingers towards

the middle finger. Assist lumbricals. DABS- 4 Lie between spaces of metacarpals. Abducts the 4 fingers

away from midline of hand and assist lumbricals in flexion and extension of joints. Also shapes fingers to fit objects

Lumbricals originate from medial 3 tendons of FDP and insert into tendons of the EDC by the proximal phalanges. Coordinate tension between flexors and extensors, control balance of index and thumb.

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What is the role of the lumbricals and interossei in hand function?

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Let’s take a look at the interossei and lumbricals

What about in hand manipulation skills? Are they important?

In hand manipulation skills are important for speed and accuracy.

Using your other hand is not efficient for pencil rotation, and you risk dropping your pencil

Pencil rotation with the writing hand is important as well as finger <>thumb shift for many fine motor tasks

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AP- Largest muscle with two heads , Strongest of pinches, Adducts thumb . We need to think about strengthening the thenar musculature and not this muscle as it is already strong

Origin: 1 from 3rd metacarpal and one from capitate Insertion: Proximal phalanx of thumb

Lumbricals: 4 muscles that link extensor tendons to finger tendons Flex MCP joints and extend IP jts.

Interossi DABS- Dorsal 4 Abducts at MCP jts Origin: Lat/Med Heads of Metacarpals Insertion: Extensor Hood PADS – Palmar 3 Adducts at MCP jts

Origin: Med/Lat Surface of MCP jts. Insertion: Extensor Hood

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To Review

We spend a lot of time worrying about pencil grasp and working to change grasp through the use of grippers. If you look around, you will see pencil grip variations from many highly successful and functional people. Dysfunctional grasps are ones that are inefficient since they decrease the speed or accuracy of ones work, cause one to fatigue faster or can potentially cause injury or damage.

What does recent research say about pencil grasp?

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3 groups of adults observed for grasp

58 OT students

314 voters signing their ballots

113 medical students

Most frequently used grasp was dynamic tripod 86%

Second most frequently used grasp – lateral tripod 10%

Bergmann, K. Incidence of Atypical Pencil Grasps Among Non dysfunctional Adults AJOT August 1990, vol. 44#8 736-740

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Interesting Study- Bergmann, K. Incidence of Atypical Pencil Grasps Among Non- dysfunctional Adults

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Pencil grasps are characterized by the position of the thumb, number of fingers on the barrel of the pencil and the finger joints position. Immature grasps rely on extrinsic muscles and mature grasps rely on what? 1)Dynamic tripod: Most optimal (3 fingers on pencil), small movements

of the fingers DT 2)Dynamic quadropod: 4 fingers on pencil (thumb, 3 fingers) DQ

Lateral grasps: Thumb crosses over the pencil stabilizing it against the other fingers. Pad of thumb tends to contact the lateral border of index finger 3)Lateral Tripod second most common grasp in literature, used more

by girls LT 4)Lateral Quadropod 4 fingers on pencil LQ

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What are the 4 functional hand grasps ?

Pictures of Adult’s Grasp

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No kinetic differences among grasps in the groups of 74 children in grade 4

Where grasps were grouped according to thumb position, the adducted grasps exhibited higher mean grip and axial forces

Kinetic differences resulting from thumb position seemed to have no effect on speed and legibility . Pencil grasp patterns did not influence handwriting speed or legibility

Intervention: Focus more on speed and letter formation

Schwellneus, H., Carnahan, H et al Writing Forces associated with four pencil grasp patterns in grade 4 children AJOT 2013 March;67(2):218-27

Research on Pencil Grasp

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Functional grasp is a grasp that produces a legible written product in which the child can write long enough to keep up with class work

LT grasp linked to earlier fatigue . So does pencil grasp influence writing endurance?

Conclusion: Neither grip pattern nor number of fingers on pencil had significant effect on force. Thus, all 4 discussed were equally functional for writing in grade 4. Thumb position did not effect speed or legibility of writing. However, larger amount of force is exerted on pencil when thumb is adducted.Schwellnus, H. Carnahan, H et al. Effect of Pencil Grasp on the Speed and Legibility of Handwriting in Children AJOT November/ December 2012 Vol 66 #6

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More Research on Pencil grasp

Significant difference in letter legibility on short task and long task

No significant difference found in scores between dynamic tripod and atypical grasp

Type of grip did not affect handwriting legibility or speed.

Limitations: Small sample size =46

Dennis, JL Swinth, Y Pencil Grasp and children’s handwriting legibility during different length writing tasks

AJOT 2001 Mar- APRIL;55(2): 175-83

More Research on Pencil Grasp

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Funky Hand GraspStatic Radial

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School Tool Use What is wrong here?

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Funky Hand Grasp- What makes this funky? Static Whole Hand grasp with lateral thumb

placement

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Funky Pencil Grasp- What makes this funky? Look at fingertips Radial Digital

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Last Funky Grasp- I promise!Radial Digital with tucked thumb and

closed web space

What is the impact of prolonged graphomotor tasks on tripod pinch strength and on handwriting process and product?

Participants: 51 children in 3-5th grade who were divided into two groups 23 with dysgraphia and 28 typical. Participants performed the visual-motor control subtest of Bruinks Oseretskyand a handwriting copying task

Results: <d tripod grip strength in the children with dysgraphia . This resulted in a decrease in handwriting process and product . Pinch needs to be considered when evaluating children with dysgraphia

Engel-Yeger, B., Rosenblum, S, Disabili Rehabil 2010:32(21):1729-57

What about the role of pinch and grip strength in handwriting performance?

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Did you know that the longer the finger, the stronger the finger? Did you know that grip strength increases with age? Did you know that boys have greater pinch strength than girls after age 10

after which boys are significantly stronger ? Did you know that right handers were significantly stronger in their

dominant hand, while left handers do not show any difference between the hands?

Did you know that that right handed children are expected to be 10% stronger with their right hand?

Normative data were slighter lower than 80s data in USA and Australia Dynamometer and pinch meter should be used to assess grip and pinch What is the strongest pinch? 3 pt, Lateral, or tip? Hager- Ross, C. Norms for grip stength in children aged 4-16 years Actaa

Paediatr 2002:91(6): 617-25

Finger StrengthHow much do we know?

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Age Hand Mean- Males Mean- Females

6-7 RL

32.530.7

28.627.1

8-9 RL

41.939.0

35.333.0

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Average Performance of Grip StrengthMathiowetz , V. et al . AJOT 1986 Grip and Pinch Strength Norms for 6-19

Age Hand Mean – Males Mean- Females

6-7 RL

10.09.2

9.08.4

8-9 RL

11.611.2

10.710.3

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Palmar Pinch

Growth and neuromuscular maturation affect norms

Grip strength increased with age in both hands Dominant hand produced higher grip strength than non

dominant hand Boys were stronger in the youngest group of 4-6 years old by 24-

34%, for the middle group 7-9 years boys were 2-9% stronger, and the oldest group the boys were 3-11% stronger

To be used in a clinical setting Grip strength data lower in this study as they used no form of

suspension Molenar,HM Selles, R et al. Growth Diagrams for Grip Strength in

Children Clin Orthopep Relate Res 2010 January 468(1):217-223

Growth Diagrams for Grip Strength in Children

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What about in hand manipulation?

What is it? In- hand manipulation is the

ability to position and move objects within one hand without the other hand’s help

Translation: Movement of object between palm<> fingertips

Shift: Moving objects between fingers

Rotation: Turning an object using the pads of the fingers

Dreidel & Coins video (#461)

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More In- Hand Manipulation

Insert 038 44

Squirreling coins into bank video – finger to palm translation (#384)

Links with Finger shift video – (#468)

Pencil Rotation (#369)

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What about pencil rotation?

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Is there a way to measure dexterity in children?

There is no standardized way to measure fine motor dexterity in children.

Is there a tool that is simple and easy to use?

9 -HPT is a timed test. Smith et al. developed

normative data for children 5-10 years old. High inter-rater reliability and test –retest reliability were found

406 children from ages 4-19 were tested .Majority right handed . Only normal subjects with no neurological ,orthopededic or Special Ed. Classifications were used.

Results: Speed of dexterity improved with age. Times for children 4-9 were >d significantly . Females performed faster than males and dominant hands are faster than non dominant hands.

Poole, H. Burtner, P, Torres, T, et al. Measuring Dexterity in Children Using the Nine Hole Pegboard Test Journal of Hand Therapy 2005 July- September 348-351

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Fine motor tasks are an integral part of elementary school education

There is a lack of simple and easy tools that are reliable and valid This study was conducted to establish normative data for children

aged 5-10, establish test retest reliability and inter-rater agreement, assess concurrent validity and construct validity

Participants: 826 students from age 5-10 in 7 public schools from rural as well as metropolitan area

Extremely high inter-rater reliability and high test-retest reliability were found

Smith, Y and Hong, E Normative and Validation Studies of the Nine Hole Peg Test with Children Perceptual and Motor Skills 2000,90, 823-843

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Normative and Validation Studies of 9 hole Peg Test with Children

9 Hole Pegboard Test

What does this measure?

Any in hand manipulation?

We can have a means of comparison using this test

It is commercially available, easy and quick to administer, portable, and has minimal space requirements

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9 hole pegboard test (#377)

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Strengthen grip, pinch, intrinsic muscles, wrist muscles etc.

There are many low tech ways to do this

Work on in hand manipulation skills to increase speed and accuracy

How can we help our children now that the Common Core is here ?

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Rapper Snappers

Wrist Strengthening- Rapper Snappers

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Wrist Y’s with band video (#437)

Wrist Strengthening- Wrist Y’s with bands

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Thumb Strengthening with putty

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Video 006

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Thumb strengthening using geo-board

Tripod Pinch Strengthening with putty- Buried Treasure

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Magical Mystery Tour – pincer/tripod grasp video (#453)

Pick up Sticks video (#470)

Clothespins word game video (#290)

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Tip pinch strengthening and desensitization-Magical Mystery Tour and Pick Up Sticks

Video 0465

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Tip pinch strengthening using bubble wrap

Pinch Strengthening with eggCrack the egg

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Crack the Egg

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Video 0412

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Tripod Pinch strengthening with clothespins

Video 0421 Spider Webs

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Intrinsic Muscle Strengthening-Spider Webs

Video 0451

Lumbricals Muscle Strengthening with Sharks or Duck Bills

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H.C. is a sweet 6 year old girl who has repeated the first grade. She demonstrates tactile sensitivity to pencils, delayed fine motor skills with a tripod grip now emerging, and low tone with weak musculature throughout. In addition, poor graphomotor and visual motor skills are noted. H.C. pulls out her hair and sucks on her shirt. She has used a necklace in the past to suck on. Her strength is in her verbal communication but she struggles to modulate her voice.

H. C. takes longer to perform the morning routine such as taking off her backpack, getting her chair down to the floor, and putting her coat away. She has difficulty putting her books away in her desk and placing papers in her folder.

She is now on grade level for all subjects except for writing.

What is the role of Occupational Therapy to help her meet the demands for the

common core?

What would be some appropriate goals?

Case Study

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H.C writing and cutting

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Writing with golf pencil –inefficient grasp video (#0343)

Poor scissor grasp (#0386)

H.C. Writing with claw and slant board , looped scissors

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Writing with claw & slant board video (#0388)

With loop scissors video (#0387)

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Video 0533

Video 002

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HC on 6/16/14 and 12/14

What about scissor skills? Is that lost to a new generation?

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There has been little research on this issue. It will be interesting to see what happens down the road. Will education revert more to a developmental approach when they see the difficulties that children are having?

What type of scissors should we use?

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How has the Common Core

affected Occupational Therapy in your state?

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Discussion Question #1

Do you work on goals to reinforce the Common Core? What are some

of the tools that you use to achieve this?

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Discussion Question #2

I hope that I have provided food for thought.

Think about the children you work with and the increasing demands placed upon them for output.

Can we have a bigger role in the Common Core curriculum development ?

Is it time that the educational system considered the developmental needs of all students and made all classrooms user friendly?

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Conclusion

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Dynamic tripod is not the only functional pencil grasp. There are other grasp patterns that can be functional

We will need to educate teachers and parents regarding functional vs. dysfunctional grasps

Use of grippers, smaller/larger pencils have to be carefully explored. They may not improve the quality and timeliness of work

We may need to use other FOR than developmental frame of reference

We need to remain on top of classroom requirements Thank you for your time, attention and consideration

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Conclusion (con’t)

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Contact Information

Naomi Aaronson – pilatesot@gmail.com