NEUROKINESTHETIC APPROACH TO HAND FUNCTION AND HANDWRITING

Presented by

Mary Benbow, M.S., OTR

Understanding the Hand from the Inside-Out

Developmental Activities Based on Hand Anatomy

Mary Benbow, MS, OTR

RELEVANT ANATOMY Normal use and function of the hand are dependent upon the synergy of many muscles; those acting on the wrist, as well as the digits. The muscles of the wrist are important because they stabilize and prevent unwanted wrist movements, which allow the finger muscles to maintain an adequate length that is favorable for producing tension and prehension. The muscles of the hand and wrist are so closely linked that it is virtually impossible to voluntarily omit a muscle from the synergy of which it belongs. Understanding the anatomy of the hand and wrist is important for appreciation of the intricate and synergistic function of the muscles and joints, which work so intricately to provide functional grasp, release and skilled manipulation.

WRIST EXTENSORS AND FLEXORS Finger movements should work in reciprocal synchrony with movements of the wrist. Grasp is weaker with wrist flexion than with wrist extension. Wrist extension is critical to stabilizing the structure and allowing finger movements at the best mechanical advantage for freedom of range and control. Children with fine motor and writing problems often lack good wrist stability in extension and therefore cannot activate the most functional finger movements required for skilled manipulation. To maintain good stability of the wrist in extension for distal finger function, it is necessary for the wrist flexors to work antagonistically with the wrist extensors to provide stable co-contraction and maintain the proper control of the wrist in its best functional position. EXTRINSIC MUSCLES The extrinsic finger muscles have their bellies in the forearm. These muscles narrow to pass through the carpal tunnel and into the tendon sheath. They insert on the IP joints of the digits. The extensor extrinsics are responsible for extending the MP joints of digits 2 through 5 and extend the wrist by continued action. The flexor extrinsics flex the PIP joints and the MP joints and the wrist by continued action. MUSCLES OF THE PALM The palmar aponeurosis is a fibrous tissue within the palm that is pulled by the palmaris longus, which gathers the fascia as a unit to arch the palm. The brevis draws the skin over the hypothenar eminence to the middle of the palm and also assists in palmar arching. Intrinsic muscles of the palm function primarily to move the fingers in abduction or adduction in relation to the midline axis of the hand. The palmar interossei, dorsal interossei and lumbricals function to provide delicate coordination of the digits in abduction, adduction, flexion of the MP joints while extending the PIP joints, shape the fingers to fit objects, control tension between the finger flexors and control precise balance between the thumb and index fingers.

INTRINSICS OF THE FIFTH DIGIT The little finger and the thumb have a special relationship and add to the grasp and balance of the hand. The flexor digiti minimi, abductor digiti minimi and opponens pollicis & digiti minimi are referred to as the hypothenar muscles. They work in synergy to flex the MP joint of the 5th digit, abduct the fifth digit and rotate the fifth MC joint at the CMC joint for opposition to the thumb. EXTRINSIC MUSCLES OF THE THUMB The extrinsic muscles of the thumb all have their origin in the forearm. The extensor poillicis brevis and longus extend the MP joint of the thumb and radial deviates the wrist. The abductor pollicis longus abducts the CMC joint, radially deviates the wrist and assists in slight flexion of the wrist. The flexor pollicis longus flexes the IP joint of the thumb and the MP and CMC joints by continued action. INTRINSIC MUSCLES OF THE THUMB The intrinsic muscles of the thumb are the abductor pollicis brevis, flexor pollicis brevis and opponens pollicis. These three muscles make up the skill triad and provide rotation of the thumb at the CMC necessary for active opposition, manipulation and delicate touch. The adductor pollicis is a power muscle and adds strength to opposition. HAND MOVEMENTS The structure and function of the anatomy of the hand and wrist are responsible for an almost infinite combination of skilled movements of the digits, supported by stability of the wrist and elbow, arches of the hand and the joints of the upper extremity. If one considers the intricate movements of the hand and its skills, the many problems, which can arise in writing and manipulation, can be appreciated. Children with dysfunctional hands show typical symptoms of a lack of neuromuscular maturity. The arches of the hand are often flat and incompletely developed. There is also a lack of motoric separation between the radial and ulnar sides of the hand. The internal stability of the hand is often in the low normal or low tone range. A related problem is in establishing good wrist stability. The digits often lack controlled flexion/extension and rotation, which are critical for manipulation. Each child must be carefully assessed for the specific degree and area of dysfunction, so that appropriate developmental hand activities can be used to prepare, strengthen and develop the components of functional hand, wrist and finger movements.

WRIST EXTENSORS AND FLEXORS WRIST EXTENSORS AND FLEXORS

EXTRINSIC EXTENSORS OF DIGITS

EXTRINSIC FLEXORS OF DIGITS

PALMARIS LONGUS

INTRINSICS OF DIGITS

JOINT POSTURES AS THEY RELATE TO POSITION OF LATERAL BANDS

INTRINSICS OF DIGIT V

EXTRINSICS OF THUMB

INTRINSICS OF THUMB

POWER MUSCLES OF THE THUMB

SKILLED MUSCLES OF THE THUMB

DEVELOPMENTAL PATTERNS

WRIST POSTURE GRASP PATTERN

3 months Wrist Flexed Digits 2 & 3 flexed Thumb adducted No pressure control of object

5 months Wrist flexed Grasp with symmetrical digits Thumb adducted

6 months Wrist straight Radial palmar grasp Web space opening

8 months Wrist extended Radial digital grasp Opposition

9 months Wrist stable in extension Distal digital manipulation

10 months Wrist stable in extension Thumb opposed to radial digitals for 3 jaw

chuck

grasp Pincer grasp with slight flexion at each radial digital joint

ANATOMICAL BALANCING MECHANISMS FOR HAND FUNCTION FOREARM The radial INNERVATED supinator works in balance with the median innervated pronator teres. WRIST Prime stability at the wrist comes from the wrist extensor located diagonally opposite to the side of the hand, which is functioning. Therefore, when the radial digits (ii & iii) and thumb are manipulating, the extensor carpi ulnaris serves as the prime stabilizer. When the ulnar side of the hand is incorporated for power, the extensor carpi radialis brevis is the prime stabilizer. Anatomical fixed and mobile structures within the hand allow it to rotate around its "midline." RADIAL DIGITS Carpometacarpal joints are essentially fixed to stabilize the palm in opposition and provide the proximal stability for the highly mobile MP joints of digits ii & iii. Metacarpal phalangeal joints are diarthrodial and they are very mobile to allow movement in three planes. ULNAR DIGITS Carpometacarpal joints are mobile Digit v range of motion is 25-30 of motion at the little finger articulation. Digit iv range of motion is 15 at the ring finger. Metacarpal phalangeal joints are diarthrodial joints. They are less mobile than the radial MP joints but allow limited movement in three planes. THUMB/FINGER STRENGTH BALANCE Thumb: the intrinsics muscles are the stronger group. Fingers: the extrinsics muscles are significantly stronger. Finger strength: the longer the finger, the stronger the finger Whole hand function: the peripheral digits i and v balance each other in total hand patterns.

Hand Anterior View

INEFFICIENT GRIPS

EFFICIENT GRIPS

Altering an Inefficient Grip

In development of motor skills, there is evidence of transfer between different forms of action. The precision grip once mastered and reliably used with a spoon begins to be used in drawing with a pencil. Therefore the instructor or therapist should evaluate the childs skills in use of a spoon or fork before attempting to alter the more complex skill with a writing tool. Silverware requires only stabilization with the skilled digits. A writing tool requires stabilization with mobilizing. If the child uses an immature power grip on a spoon, the instructor should develop this sub-skill before advancing to writing tools. Hand structures required for tool stabilization with distal manipulating are:

a) Active metacarpal phalangeal arch with three degrees of freedom (flexion/extension, adduction/abduction, and rotation) at the metacarpal phalangeal joint of the index finger.

b) Full range of motion at the carpal metacarpal joint of the thumb is required to stabilize

the open web space. Conditions a & b may require therapeutic intervention with specific developmental activities to achieve the desired results.

c) Joint stability; a most prevalent finding is ligament instability within the joints of the

hands. Shifting the pencil into a more stable web space between the index and ring fingers is often a convenient intervention. In severe cases the use of a neoprene splint, as an outside stabilizer may be required.

Before intervening with a student with an inefficient grip, it is critical for him to understand why it is worth his effort to change it. Pencil grips that are not held within the pulps of the digits do not lead to economy, variety and convenience for proximal-distal axis in the simple flexor or extensor synergy to produce fast enough writing needed once the output demands increase about third grade. An adducted grip (which diminishes the proprioceptive input from the lumbricales from the skilled digits) does not allow the luxury of the unconscious regulation of the gripping pressure on the shaft of the pencil or the downward pressure of the pencil point against the writing surface. This is the reason many students frequently need to stop, release their grip on the pencil and shake the pain out of the fingers. He should be made aware that power grips might result in painful joint dysfunctions later in life due to the stress they cause to the support structures of the joints. The following sequence can make the transition to the functional grip less stressful and more successful. 1.The instructor demonstrates how to position a pencil between index and long finger to make large random patterns on the paper using only shoulder and elbow movements. 2. The child imitates the instructor by positioning the between the same two digits to make large free flowing movements (no finger movements, letter or number symbols are allowed). 3. After the child adjusts to the feel of the pencil in the index/middle finger web space, she should be encouraged to draw anything she pleases.

1. Only when she feels at ease with the new pencil position should she be encouraged to

write large isolated letters and numbers. 2. When the new grip becomes annoying, the child should be encouraged to temporarily

shift back to her former grip. 3. As soon as the child feels ready, she should return to the adapted or new grip. 4. When a child is in control of the alternating time shifting scheme, and experiences

comfort and success, she will increase the use of the new grip more consistently. Several finger positioning devices may be used to guide the writer in better placement of their fingers while holding a pencil. Although the use of a positioning device is more effective in developing an efficient grip rather than correcting one, they can provide some comfort and positioning benefit. The Pencil Grip is large enough to block distal inter phalangeal (DIP) joint hyperextension in most five and six year olds. The Pencil Pal was designed to reduce hyper extension of the DIP joint of the index finger by stabilizing the pencil at the level of the MP joint rather than deep within the thumb web space. The increase in the angle of the pencil reduces white knuckle discomfort in many children, allowing dynamic control of the pencil with the skilled digits. Micro-foam Tape is effective when low tactile sensitivity is a contributing factor. The instructor can apply a narrow strip wide of stretchy tape over the dorsal aspect of the writing digits to increase the flow of afferent impulses. The tape should be firmly affixed to the finger- nail and gently stretched over the mid-dorsal aspect of all three-finger joints and onto the metacarpal bone. The additional sensory input allows the child to have more control of his written output.

DEVELOPMENTAL HAND SKILLS OBSERVATION

The following observation assessment is designed for the primary child. Each item provides information on specific aspects of hand skill required for good coordination and fine motor manipulation, as well as the development of cursive writing proficiency. Each observation is explained, with instructions for observation and a list of items and equipment necessary. The first three observations of supination, forearm stabilization and wrist stabilization in extension, establish the level of proximal stability and control present to support distal function. The remaining items of isolation of thumb from fingers, separation of the two sides of the hand, individuation of the digits, palmar arching, stabilization of the thumb web space, translation of digits and precision rotation with finger tips, reveal the degree of isolation, individuation and integration of the hand and digits in various aspects of hand skills.

VIDEO TAPE A detailed explanation and demonstration of Mary Benbows "Developmental Hand Skill Observations for The Primary Child," is available on video tape from Clinician's View. This video tape, entitled "Assessment of Hand Skills In The Primary Child," demonstrates normal hand skills function, the specific observation assessment of each skill, and examples of hand dysfunction. For more information on this video, contact Clinician's View www.clinicians-view.com.

DEVELOPMENTAL HAND PROGRAM The developmental hand program consists of over 65 activities designed to improve hand function, dexterity and control. The activities are divided into 9 sections, including proximal control of the shoulders, the elbow and the wrist, distal finger movements, precision translation, precision rotation, motoric separation of the two sides of the hand, thumb activities and joint stability within the hand. Activities are easily chosen based on the observation of hand skills assessment previously described. Each of these activities is clearly explained and demonstrated in the video "Developmental Hand Program," by Mary Benbow, and available from Clinician's View. The human hand is dependent on multiple factors for sensibility of adjustment, economy of execution and accuracy of skill. This hand program has been developed to guide professionals in systematic assessment and inclusive activities to enhance the varied components of fine motor skills of children. OVERALL DEVELOPMENT Developmental therapists, trained to look at the whole body and its interrelationships, must address ergonomic factors (postural, tonal, and stabilizing) for fine motor intervention to be most effective. Fine motor difficulties listed in this handout will focus on incomplete utilization of the proximal joints of the upper extremity, immature hand development and lack of joint stability. Commonly related developmental issues such as bilateral integration and visual-motor in coordination will not be addressed in this handout. PROXIMAL JOINT CONTROL The development of dexterous hand skills depends on the interaction of all joints of the upper extremity: scapulothoracic, glenohumeral, elbow and wrist. Every joint must move freely into its mature pattern (s). Therefore, each joint should be assessed for functional mobility as it is incorporated in mature upper extremity patterns. In children who experience fine motor delays, it is common to find the shoulder slightly biased in internal rotation, adduction and/or flexion; the elbow in pronation and/or flexion; and the wrist toward flexion and ulnar deviation. In addition to adequate range of motion, every proximal joint must provide a stable base of support for the joint(s) distal to it to enable maximal control. Proximal joint instability is best treated in an adapted physical education setting with weight bearing, traction and compression type activities. SCAPULA/SHOULDER ACTIVITIES 1. BALL TAPPING: The child uses a 12" to 14" stick braced between the palms of the hands to gently tap a suspended 8-10 inch ball. The ball should be hung at a level that will require as full elevation of the arms as the child is capable of controlling. Gentle tapping will demand more mid-range control while developing more stable scapula and shoulder joints. 2. MIRROR ARM PATTERNS: Pair off. The instructor initiates a slow symmetrical movement sequence with her arms for the child to follow as if looking in a mirror. Reverse the

"leader/follower" roles. Grade by working at a higher level and/or at a slower pace. An advanced goal would be for observers to detect which person is the leader of the sequence. 3. PRECISE POURING: (Pouring from a pitcher or a watering can requires controlled distal mobility, or proximal stability). Fill the container to the level that challenges the strength limitations of the child. Pour colored water into several small containers without spilling between them or overflowing their rims. Work for accuracy with more fluid (weight) in the container and/or reduced quantity containers. 4. SPHERE ON SPOON CARRYING: Carry a round ball, marble, or stone at arms length on a long handled wooden spoon. Grade by positioning the grip more distal from the bowl of the spoon, increasing the weight of the sphere or distance to be traveled. A final goal could be to carry a heavy sphere to a target with the eyes closed. 5. ROPE TURNING: Turn one end of a jump rope with a partner. The child should first use his dominant hand to develop external rotation of the dominant side shoulder. Then he should turn to use the non-dominant hand to develop the other shoulder. 6. ROPE JUMPING: Self-swing a jump rope. (The handles of the jump rope should touch his armpits -when the child stands with feet together with the middle of the rope passing under the arches). Swing the rope backwards over the head. Reverse swinging requires movement of all upper extremity joints into their mature patterns. Initially, the child should concentrate only on swinging the rope. When he hears the rope strike the floor behind himself, he should step backwards over it. 7. PLAY BOY: The elliptical form is forced to opposite ends of the strings when the child abducts at the shoulders. The handles can be positioned from shoulder elevation to shoulder depression. Lying supine is most beneficial for the child with low tone who has scapula instability, poor balance, or isolated control of his upper extremities. 8. BLACKBOARD SHOULDER LOOPS: Produce external rotation loop (overhand) patterns with chalk on a blackboard. Start at eye level and midline and move as high and wide as the reach will allow. Work for pattern smoothness and uniformity. Close eyes and continue patterns kinesthetically. ELBOW ACTIVITIES 1. SLINKY: The metal slinky should be shifted back and forth while being maintained in a full palm up position. 2. MAGNET STICK FOR VISUAL TRACKING: The child horizontally holds the tracking card with his non-dominant hand to guide a metal object along a printed track. He guides the metal object by sliding a magnet (glued to one end of a stick) from beneath the card track. The magnet stick should be held in a tripod posture with the dominant hand. Start by guiding a flat metal object (paper clip or safety pin), which requires less exact supination. Advance to guiding a tiny metal ball, whose tangential contact demands maintaining the magnet stick in precise supination.

3. TRACK IT: The tray containing a template and slider should be supported on forearms with fully supinated palms while being shifted to the new stimulus-directed position. 4. VOLLEY BALL STYLE ACTIVITIES: Games where the hands, paddles or rackets are used in a full palm-up position. 5. ROLLING SUPINATION: Sit straddled on an 8 stool or roller. Lean forward and take weight onto pronated forearms placed on an 18"-20" vestibular ball. From this "prone on elbows" position, slowly shift weight sideways by rolling the ball under the forearms to the right. This will supinate the (R) elbow and free the (L) arm. Increase supination range of motion by holding the joint position at the end of its range. Alternate sides. WRIST ACTIVITIES No other upper extremity joint can compensate for wrist limitations Therefore, careful evaluation and remediation must focus on this joint. Children with fine motor delays often compensate for inadequate stabilization of the wrist in the extended position by flexing the wrist to stabilize bone on bone. Lack of stabilization in wrist extension will compromise abduction of the thumb, arching of the hands, and isolation of intrinsic motor control. The extensor carpi ulnaris (ECU) is the prime stabilizer of the wrist when the index or index and middle fingers are working opposite the thumb. ECU works synergistically with the thumb triad (abductor pollicis brevis, flexor pollicis brevis and opponens) for precise manipulation. A flexion/extension interplay should be seen between wrist and finger movements as the hands are being used. The wrist and hand function as a single physiological unit, so therapists should combine wrist with hand movements into fine motor activities. 1. FLOOR ACTIVITIES: Large chalkboard or mural painting are age appropriate activities that can best be accomplished on the floor. 2. TOWEL SCRUNCHING: Place a tea towel lengthwise over the far edge of the child's desk. With forearm stabilized in full pronation (palms down) on the desk top, use finger flexors to gather the towel into the palms. As more towel is gathered, more finger flexion with wrist extension will be incorporated into this task. 3. DONKEY KICKS: Instruct the child to place his hands on a mat directly below his shoulders, with fingers pointing straight ahead. He should take his body weight onto his open palms and his tiptoes. His ankles should be touching each other at all times during this exercise. Start with both feet to one side and "kick" up and over to the opposite side of the mat. With practice, his kicks will become higher and his wrist flexors more elongated. 4. VERTICAL SURFACES: The wrist will be positioned in fuller extension the higher the child works on a vertical surface above eye level. Games and art materials can be mounted in a clipboard, set in a railing, or taped to a non-porous vertical surface. Suggested materials might include pegboards, Lite Brite, Etch-A-Sketch (turned upside down so knobs are high), Magna Doodle (turned upside down so eraser bar is high), threading eye hooks, outlining before coloring, circling, filling in small circles, and writing high with chalk on a blackboard and drawing or painting at an easel.

DISTAL FINGER SKILLS: Wrist stabilization combined with fine manipulative activities should develop the essential hand components for all high level hand skills: The components: A) develop and stabilize the arches of the hand, B) develop the two divisions of precision handling - precision translation and precision rotation; C) motorically separate the two sides of the hand, and D) open and stabilize the thumb-index web space. A) ARCHES There are two transverse arches, four longitudinal arches, and four diagonal or oblique arches of position. The arches: 1) shape the hand to grasp multiple shaped and sized objects, 2) direct the skilled movement of the fingers, and 3) grade the power of prehension. Well-developed arches enable the palm to form a deep hollow at the base of the long finger and distinct crease between the thenar and elevated hypothenar eminences when the hand is cupped. 1. PALM SHAPING: Press a ball or round object into the child's palm. Facilitate arching of his hand by stroking or shaping it into an arched posture with your hands. A gummy super-ball is a most effective texture to elicit the child's natural tactile affinity for this activity. 2. PALM LOADING: Cup the supinated palm so that a deep hollow is formed at the base of the long finger. Gradually add grains of rice or coffee while encouraging the child to make the hollow deeper to hold more. This activity should facilitate CMC flexion of the 5th metacarpal and wrinkling of skin on the little finger side of the palm. 3. SHAKING DICE: Be sure the fingers are adducted and incorporated in the longitudinal arching. Cup both hands before placing them together at a 90-degree angle to each other. Maintaining the arches and the sealing of the borders of the hands will allow the dice to shake within the palm without being dropped. 4. DOMINO THEORY: Arrange dominoes on their narrow end about 1/4 inch apart in a long line. By pushing the first in the line one should see a chain reaction of them falling in order. 5. PLASTIC BAG SEALING: Bilaterally seal Zip-Lock Bags. Pinch the grooved ridges together at the middle, the thumb pulps working opposite the finger pulps. During successive trials, work with the thumbs opposite each finger pulp from index to little finger. Encourage maintaining a rounded thumb web space as you seal the bag. Color change seals are best. 6. TOWER BUILDING: Hold chisel erasers between each thumb and index finger. The points ends should be positioned toward the web space. Pick up tiny cubes or dice from a table surface by compressing them between the round open ends of the erasers. Stack the cubes to build a tower. Controlled bilateral release is essential for the tower to reach great heights. 7. SPIDER ON THE MIRROR: (One forearm should be fully supinated and the other fully pronated to do this exercise.) Place like finger pads of each hand together. ABduct and ADDuct extended fingers. Some flexion/ extension will happen at the MP joints as part of this finger pattern, as the deep hollows are formed at the bases of the two long fingers.

8. THERAPLAST BALLS: Shape a 3/4" sphere by cupping the hands (including the fingers) within the hollows of the hands. Grade this activity by dividing the putty and simultaneously shaping two balls with the two hands. 9. CHINESE BALLS: Use two 3/4" marbles, wooden beads or super balls in each hand. Rotate one ball around the other within the palm(s). Different colors help the child motor plan and determine if they are rotating around each other. The rotation pattern that requires the thumbs to move toward the middle of the palms will require use of the triad muscles of the thumb. HAND TOOLS Many hand tools are held using an oblique arch of opposition. (This grip is customarily assumed to cut food with a table knife). The tool handle is positioned diagonally across the palm with the index finger extended to provide stability and downward pressure to perform the task. The material to be cut must be soft enough so that an ADDucted lateral pinch will not kinesthetically be substituted for additional power to perform the task. 10. WINGED CLOTHESPIN: Glue a cross bar (half a Popsicle stick) onto the end of the handle of a wooden clothespin. The child should place four finger pulps on this affixed cross bar and his thumb pulp on the opposite handle to open the clothespin. This posture will strengthen the thenar muscles as the child works. 11. DRESS MAKER'S WHEEL: Guide a Dress Maker's wheel to serrate heavy paper for easier tearing. Using dress maker's colored paper, guide the wheel to make colored dotted designs. 12. STRAWBERRY HULLER: Arch the fingers to the same length. Place the four fingertips on one side of the implement with the thumb on the opposite side. Pick up small objects of various textures without crushing them and move them to another location or stack them. 13. ESCARGOT HOLDER: Place four finger pulps on one side of the handle with the thumb pulp on the opposite handle. This posture will strengthen the thenar muscles as the child picks up and transfers objects. 14. ROOKIE STICK: The two legs of this device will guide an open web space while developing delicate touch with small objects. 15. OLIVE & PICKLE PICKER UPPER: This plunger device can direct resistance to specific areas of the thumb triad while maintaining control of distal pressure. 16. PLASTIC KNIFE CUTTING: Cut clay, putty, bread or partly cooked carrots etc. with a "fast-food" restaurant knife. The tool handle is positioned diagonally across the palm with the index finger extended to provide stability and downward pressure to perform the task. The material to be cut must be soft enough so that an ADDucted lateral pinch will not kinesthetically be substituted for additional power to perform the task. B) PRECISION HANDLING (TWO TYPES) Distal precision handling requires full range of motion at the carpometacarpal joint of the thumb. Full abduction with medial rotation positions the thumb so it can be placed diametrically

opposite each of the finger pads. From this full range position, the multiple variations of the two precision handling skills should be developed and refined. PRECISION TRANSLATION Precision translation requires that the thumb and index, or thumb, index/middle fingers move in synchrony in a "toward palm" and/or an "away from palm" pattern. Needle threading utilizes a "translation-away pattern" from the fully flexed "translation toward the palm". Intrinsic muscles are used in the away pattern and extrinsic muscles are used in the toward pattern. 1. BEAD STRINGING: String beads or lace cards by inserting tip of the lace through the opening with the thumb and index finger. The natural compensation of placing the bead or card over the tip with the non-dominant hand is often observed in the child who needs this skill. 2. EYE-LOOP DESIGN BOARDS: Lace a design board that is outlined with eye-loops. The board should be secured to a vertical surface to facilitate wrist extension/thumb abduction needed for distal finger movements. 3. DISTAL STICK FLIPS: Withdraw 2 inch stick(s) using the thumb and index finger pulps (translation toward the palm) to remove the stick from the center(s) of wooden beads mounted on a vertically placed design board. Flip the stick end-over-end within the distil fingertips and reinsert the stick by extending (translation away from the palm) the two digits. 3. PEG BOARDS ON VERTICAL SURFACE: Withdraw and insert pegs using isolated finger movements. Upward progressions of the pegs in the grid from the bottom to top of the board will require more wrist extension as the child advances toward the top. 4. INCHY THE INCH WORM: Inch a pencil or chopstick positioned in a tripod posture toward and away from the palm. The shaft should rest in the open web space as it is inched along using "translation toward" or "translation away" finger movements. 5. SQUIRRELING OBJECTS INTO PALM: Stabilize forearm with palm down on a tabletop. Pick up small objects (unit cubes, mini-marshmallows, beads, Cheerios etc.) with the thumb index and middle fingers. Translation toward the palm movements should be used to "squirrel" objects into the palm. Storing multiple objects under digits 4 & 5 will inhibit their movement. 6. DE-SQUIRRELING OBJECTS FROM PALM: Methodically release objects one by one using a "translation away" pattern of the objects stored during activity above. 7. GRAPHIC UP STROKING/DOWN STROKING: Stabilize the wrist in normal writing posture on a desktop to inhibit all but finger writing movements. Make a series of 10-15 diagonal down strokes to assess length of isolated finger reach of translation movements in the toward" the midline pattern. Repeat with an up stroking series to assess length of isolated finger reach of translation movements in "the away" from the midline pattern.

PRECISION ROTATION Precision-rotation is required: i) to shape the grasp, ii) to turn an object over and over between the finger, and iii) to rotate an object positioned within the fingertips. A well-developed transverse arch at the metacarpal level enhances precision rotation. 1. i) FINGER TUG-OF-WAR: (Sequence use of the two muscle systems-intrinsics shape the finger to secure the grip so extrinsic power will be effective). The child is instructed to tightly grip a small diameter object such as a plastic lace, coffee stirrer, etc. between his index finger and thumb. Once the object is securely grasped, the challenge is to resist tugging from his other hand or a partner. 2. i) GRASP MOTOR PLANNING: Pre-position the fingers to prehend varying shaped and sized objects. Have the child motor plan the approximate fit before trying the object into the curved fingers for size. Grade by having the child approximate the grasp with the hand outside of his visual field. 3. ii) WEDGE SPONGE: Flip a cosmetic wedge sponge in-between the distal finger bones with the thumb. Flip it from thumb to little finger sides of the hands before reversing the pattern. 4. ii) UNILATERAL PENCIL ADJUSTING: Flip a pencil from writing position to erasing position. 5. iii) COIN EXAMINATION: Rotate a coin held horizontally in the fingertips to read the words around the head. 6. iii) WATER DISH ROTATION: The initial posture is with the elbow stabilized on a table top in full supination. Place a 2" "filled-to-the-brim" dish of water within the fingertips. Rotate the dish in a clockwise pattern. Grade by removing elbow stabilization, then have the child walk about while rotating the dish and lastly have the child walk about while rotating the dish with his eyes closed. Have the child position the dish laterally away from his midline for the greatest challenge. 7. iii) CIRCLING WITHIN CIRCLES: Fill in tiny circles or the letter with a pen or marker using distal circular patterns. 8. iii) SPHERE FORMATION: Roll out pea sized balls 1/16" to 1/8" between the pulps of the thumb and the index finger-or thumb and index and long fingers. (Theraplast, clay or straw wrappers work well). C) MOTORIC SEPARATION OF THE TWO SIDES OF THE HAND Refinement of skill with the radial side of the hand is best achieved when the ulnar side of the hand is stabilized. When digits 4 & 5 are flexed against the palm or are postured in extension combined with abduction of the little finger, this posturing will stabilize the metacarpal-phalangeal arch and localize control to fingers 2 & 3. With this separation the radial or skilled digits can manipulate more precisely with the thumb.

Early hand separation starts when the infant crawls and bears weight on the ulnar side of the hand while carrying toys with the radial digits. Developmentally this activity elongates the muscles on the ulnar side of the hand and inhibits fingers 4 & 5. 1. PENNY FLIPPING: Arrange pennies heads up on the "Penny Turning Sheet". With thumb working against the fingertips (index or index + long finger) flip the 21 pennies as quickly as possible. Start with the dominant hand, followed by the non-dominant hand, and lastly turn the sheet to work bilaterally 2. TRIGGER FINGERS: Squeeze the trigger of a spray bottle with fingers 2 & 3 while holding the bottleneck with the opposed thumb and fingers 4 & 5. 3. FINGER PATTERN GAMES: (Start by having the child seated at a table or desk. Position his palms over small balls that support the arching of his palms). Instructions should include specific fingers to lift, separate, bend or straighten. Grade from visual monitoring to kinesthetic control of the digital patterns. Bilateral finger patterns are often less stressful for young children.. 3. SPHERE FORMATION: Roll out tiny balls 1/16" to 1/8" between the pulps of the thumb and the index and long fingers. (Theraplast, clay or straw wrappers work well). 4. GRASP-RELEASE SPLITS: The childs hand encircles a round object (therapists wrist is the ideal) with a four finger cylindrical grasp. The child is instructed to: a) release pressure with the radial digits while maintaining grasp with the ulnar digits, b) return to a full cylindrical grasp, and c) followed by release of pressure with the ulnar digits. Alternate sides for grasp/release while reducing overflow between the two sides of the hand. 5. UNILATERAL LID TURNING: Hold a tube of toothpaste across the palm in one hand. With thumb and radial digit(s) screw/unscrew the loosened lid. 6. SCISSORS: The proper handling of scissors requires a stable extended wrist, motoric separation of the two sides of the hand, and proficiency in alternating flexion and extension movements of the radial digits. Tweezers with small handles work well as a preliminary tool for younger children to learn opening and closing blades. The scissors should be positioned with the long finger and thumb placed into small oval loops to the level of their distal joints. The index finger should rest against the shaft of the handle to support the scissors in a vertical position and help close the blades. The ulnar digits should be flexed and pressed against the palm to support the MP arch. The kinesthetic pattern to control the blades should be rhythmic before cutting materials are introduced. Proper sequencing of materials from those that take little control from recessive hand to paper or cloth will ensure success without frustration. (Tiny straws, oak tag, old playing cards are good progression for the novice cutter). 7. SQUIRRELING OBJECTS INTO PALM: Stabilize forearm with palm down on a tabletop. Pick up small objects (unit cubes, mini-marshmallows, beads, Cheerios, or coins for older children) with the thumb, index and middle fingers. Translation toward the palm movements should be used to "squirrel" objects into the palm. Storing objects under digits 4 & 5 will inhibit them.

8. DE-SQUIRRELNG OBJECTS FROM PALM: Methodically release (translation away pattern) objects one by one stored in above activity without dropping. With older children a tactile discrimination demand can be added when a penny, nickel or dime is requested. 9. SNAP FINGERS: Position thumb pulp diametrically and firmly opposite the pulp of the long finger before moving the two digits laterally in opposite directions. (Note: The ulnar digits must be separated and in a stable posture; the index finger must be separated out of the line of action). (Note: The range of motion of the carpometacarpal of the thumb as alternate cause of failure with this hand skill). 10. SPHERE FORMATION: Roll our tiny balls 1/16 to 1/8 between the pulps of the thumb and the index and the long fingers. (Theraplast, clay, or straw wrappers work well). D) THUMB For optimal distal manipulation, the thumb must move into full abduction with medial rotation to gain stability to work opposite any distal fingertip. At the full range, this complex saddle joint (CMC) will be stabilized by the joint ligaments, the combined action of the long and short extensors, the long abductor, the flexors and adductor. This thumb position allows diametric opposition to all fingertips for delicate manipulation. From this posture the triad muscles, those most densely supplied with receptors, will guide movements and regulate the pressure for speed and dexterity. Manipulative activities done on vertical surfaces above eye level will position the wrist in full extension. This wrist posture when stable will facilitate thumb abduction for diagonal and/or longitudinal arching of the palm. 1. THUMB RESISTIVE EXERCISES: The child is instructed to make perfect circles with the tip of his thumb and index finger. The therapist places his index fingers into the open web space and tries to pull the circle open. This combination of digits will strengthen primarily the flexor pollicis brevis. A perfect circle with the little finger when resisted in the same way will primarily strengthen the opponens. 2. SHUFFLING CARDS: Hold each half deck of cards in arched palms. The far end of the cards should be braced within the DIP joint creases of fingers 3, 4, & 5 and the close end should be braced against the pulp of the thumbs. The index fingers should be partially flexed and placed on the card stack backs. Pressure is exerted to the middle of the backs of the cards by gradually extending the index fingers. The close edges (thumb braced) from each half deck should be interlaced. This shuffling of cards will expand and stabilize the thumb CMC and MP joints. 3. SIT PULL THROUGH: Child sits long-legged on the floor with his hands placed on floor at his sides. The fingers should be together and fingers pointing away from his body. The thumbs should be separated as widely as possible from the index fingers, in taking his weight onto the heels of his hands in order to slide his body backward, he will naturally expand the thumb web spaces to allow full abduction of the CMC joints.

4. DOMINO THEORY: Grasp each domino between the thumb and index pulps and position it about 1/4 inch from the preceding domino along a straight or curved line. Once 20-25 dominoes are lined up on their narrow end, tip the first domino to set off the successive reaction of falling the entire line. 5. PLASTIC BAG SEALING: Bilaterally seal Zip-Lock Bags. Pinch the grooved ridges of the bag together at the middle with the thumb pulps working opposite the finger pulps. Work with the thumbs opposite each fingertip from index to little finger. Encourage maintaining a rounded thumb web space while sealing the bags. 6. COMPRESSOR ERASERS: Hold chisel erasers between each thumb and index finger. The pointed ends should be positioned toward the web space. Pick up tiny cubes or dice from a table surface by compressing them between the rounded ends of the erasers. Build a tower. Controlled bilateral release is essential to reach great heights. JOINT STABILITY WITHIN THE HAND Digit joints are most dependent on ligaments for stability. Hypermobile joints are usually the cause of collapsed thumb web spaces and hyperextension of the distal IP joints in the fingers. Tasks that demand intrinsic input can help stabilize the MP joints through action through the collateral ligaments. 1. SEALING THE GRIP: Position a 1/2" diameter snake of Theraplast or clay at the level of the MP joints crease. Have the child flex his fingers as far as possible with the long flexors. When the motion stops, adding an additional jolt to seal the grip will be done with the interossei muscles. 2. RESISTIVE ARCHED ABDUCTION OF FINGERS: Stretch a rubber band into a rounded configuration with the distal phalanges of the five digits. With the other hand pinch and shift a small clothespin graded for strength from one space to the next around the rubber band. Change hands and repeat the exercise. 3. WAITRESS TRAY CARRYING: Support a tray on extended fingers. Balance weighted objects on the tray graded for resistance. 4. DISH DRYING: Hold dishes and dry them with a dishtowel. 5. WRINGING BY HAND: Wring water out of small clothes or sponges that fit well within the curved fingers.

DEVELOPMENTAL HAND SKILL OBSERVATIONS: THE PRIMARY CHILD Developed by Mary Benbow, MS, OTR

DEVELOPMENTAL HAND PROGRAM RECOMMENDATIONS Name Age Date________ SPECIFY HAND PROGRAM ACTIVITIES: 1. Increase supination 2. Stabilize forearm 3. Stabilize wrist in extension 4. Isolate thumb movement from finger movements 5. Motorically separate the two sides of the hand 6. Stabilize thumb/index web space

7. Isolate finger(s) for their specific function 8. Develop the arches of the hand 9. Develop precision translation skill away from the palm with the tripod digits 10. Develop precision rotation skill with the distal fingertips a) precision rotation b) precision translation

Understanding the Hand from the

Outside - In

Teaching Strategies Based on Neuroanatomy

and Hand Anatomy

Mary Benbow, MS, OTR

VISUAL/VISUALIZING CONCERNS IN HANDWRITING Copying from the chalkboard (vertical plane) while writing on a desk surface (horizontal plane) requires plane' integration (a parietal lobe dysfunction) to follow the spatial directions; or the problem may be an accommodative difficulty with the needed to alternate between near point and far point vision. In severe cases, both eyes may be drawn to the (R) when elevating the eyes to read from the board.

Passivity or inertia of gaze is often seen with incomplete (L) scanning or inattention. A progressive sloping of the (L) margin into (R) space will be seen as the writing moves down the page.

There may be a problem with spacing of letters within and between words in manuscript;

irregular spacing of words in cursive. Diagonals {especially (L) downward sloping} are often avoided. When used, their execution will

approximate the vertical. This will make producing manuscript letters more difficult than cursive letters. Gestalt, the overall pattern of the letters or designs will be disrupted. Elements or parts will be strung out in printing letters or drawing designs or shapes. Multi-step directions are often forgotten or incorrectly sequenced because the student did not visualize the steps to support the verbal directions given by the teacher.

Dysgraphia Subtypes

Ruthmary Deuel -- 1995

Washington U. St. Louis, MO.

Dyslexic dysgraphia

1. Spontaneously written text poorly legible, with textural complexity influencing legibility 2. Oral spelling severely abnormal 3. Copying of written text relatively preserved 4. Drawing relatively preserved 5. Finger-tapping speed normal Dysgraphia due to motor clumsiness 1. Spontaneously written text is poorly legible 2. Oral spelling relatively preserved 3. Copying of written text poor legible 4. Drawing usually compromised 5. Finger-tapping speed abnormal ***

Dysgraphia due to defect in understanding space 1. Spontaneously written text poorly legible 2. Oral spelling relatively preserved 3. Copying or written text poorly legible

1. Drawing severely abnormal 5. Finger-Tapping speed normal

MEMORY AND HANDWRITING

It is the category of "procedural memory" that is most relevant to handwriting.

PROCEDURAL MEMORY Implicit: This memory is for automatic recall of a series of movements such as riding a bike, typing, swimming, tying shoelaces, driving, or writing cursive script. When handwriting is taught to the automatic kinesthetic level, the student is using implicit memory. This allows him to free up working memory and focus his full attention on the thought he wishes to record or the words he must spell. As long as a student has to shift his attention between remembering how to produce letter configurations and formulating an idea he wants to express, he will be at risk for "output failure." In taking class notes or copying from the blackboard, he will not be able to function at the level of his true potential. Students who develop the skills of cursive writing to the automatic kinesthetic level will be able to function more effectively at academic and life tasks. There is minimal erosion of this type of memory over the life span. Though physical changes of aging may make handwriting difficult, an older person typically continues to have procedural memory for cursive writing such as a legal signature. Working: Working memory is used when the brain's "conductor" tells it where to shift focused attention moment by moment while performing a task. Working memory is needed to keep several things in mind simultaneously with one or more components "shifted to the back burner." An example is remembering the subject of a sentence while writing the predicate. In written schoolwork, problems arise when a student must also have to recall how to spell a word and configure the letters. The student will be overwhelmed and discouraged by these multiple demands when speed in note taking is required or an increased amount of written material is expected. ATTENTIVELY STORED MEMORY Semantic: The memory of words, symbols and trademarks. One tends to add words to semantic memory throughout life. This type of memory is highly resilient throughout the life span. Remote: The memory needed to win big on "Jeopardy". This includes the rapid recall of facts collected from reading, movies, school courses and everyday exposure to the world. Decline of remote memory may simply be a retrieval problem. Episodic: This is the memory of recent events-the name of the video you viewed last week or what you ate for dinner last night. You may well remember how to drive (implicit memory) but forget where you parked your car. Loss of episodic memory troubles many people. Reduction of episodic memory will make learning a new task slower than when the person was younger.

Handwriting Observations Assessment of Cursive Writing Skills

Developed by Mary Benbow MS, OTR

RELATIONSHIP OF FINGER SPEED TO BEGINNING WRITING FINGER SUCCESSION

Gr. 1

X-1SD Gr. 2

X-1SD Gr. 3

X-1SD Dominant hand 15.9 21.0 13.5 17.7 10.9 14.4 Non-dom. hand 15.5 20.4 13.0 16.9 11.2 14.3 This study consisted of six finger tasks: two finger displacement items (lifting and spreading), finger recognition, finger-thumb repetitions, finger localization and the one displayed above. The finger succession task a measure of motor planning and programming of complex, sequential movements had the best reliability and validity for assessing handwriting. In older children the alphabet-writing task that requires retrieval and production of the letters in sequence (orthographic symbols and motor output) had the best concurrent validity for assessing handwriting, spelling and composition.1

1 Source: Developmental Medicine and Child Neurology, 1992, 34, 198-215. V.W. Berninger and J. Rutberg

VISUAL MOTOR ORIENTATION AND EFFICIENCY

This sheet can provide a graphic demonstration of the visual systems control of the hand as it guides the pencil in vertical and horizontal orientations. It often clarifies the reason why some children are unable to conform to printing and writing numbers from top to bottom. Prepare an unlined sheet of 8 by 11-inch paper by drawing three (1/8 wide and 11 long) lines spaced two inches apart with a yellow or green beveled marking pen. The child should hold his pencil in a static grip (no finger movements) to draw a continuous controlled line along the middle of each colored line. With the paper turned vertically and positioned for easy viewing, the child draws a line from top to bottom along the line on the left horizontally for the third line to determine accuracy and control when drawing across the visual midline from left to right. Have the child sign his name and write the numbers from 1-10. Note orientation of lines.

VISUAL MOTOR ORIENTATION EFFICIENCY

This sheet can provide a graphic demonstration of the visual system's control of the hand as it guides the pencil in both vertical orientations. It often clarifies the reason why some children are unable to conform to printing and writing numbers from top to bottom. Trouble in visually guiding his pencil in a downward direction may indicate convergence insufficiency.

1. Prepare an unlined sheet of paper by drawing two lines 11 " long lines with a yellow highlighter spaced about two inches apart. 2. The child should position the paper vertically for comfortable viewing of the entire length of the sheet. 3. The child should hold his pencil in a static grip (no finger movements) to draw a continuous controlled line along the middle of the colored lines. 4. He should move his pencil from top to bottom along the length of the line (a) on the

left. 5. He should move his pencil from bottom to top along the length of the line (b) on the

right. 6. Have the child indicate which direction was easier for him to control and mark it with a star or happy face etc. (I have found about 25% of persons prefer bottom to top). 7. Evaluate the two drawn lines for accuracy and control of top and bottom sections. 8. Have the child sign his name and write the numbers from 1-10. Note direction of strokes in letters and numbers. You will need to observe each child while writing his name and numbers to determine the direction and the length of the stroke.

When there is a question of the child's ability to move from top to bottom, confirm your observation at the chalkboard. Prepare the chalkboard by holding a l" piece of white chalk horizontally within your fingertips and draw lines similar to the highlighter lines. Make two white vertical lines on the chalkboard a few inched apart.

9. Position the child 12" from the chalkboard. 10. The child should hold his piece of colored chalk in a static grip. Using the tip of the chalk, he should draw a line from top to bottom without shifting backward to see to work. 11. The child should repeat a second line moving from bottom to top.

12. Evaluate his two drawn lines for accuracy and control in low and high space.

I have screened whole classes of children using prepared sheets of paper. I followed up with any child on the chalkboard if he has trouble with the top to bottom movement or has not converted to our top to bottom cultural demand.

DIAGNOSTIC OBSERVATIONS BY LETTER GROUPS

GROUP: CLOCK CLIMBERS

RANGE OF MOTION--Children who have trouble rounding strokes over the top between 11 and 1 o'clock often are tight in forearm supination, index metacarpal phalangeal rotation and/or thumb abduction. Any closed web pencil grips severely limit rotation of the pencil point. Therapeutic intervention is usually indicated.

DIRECTIONALITY--Continuous pattern, "roller coaster" or wrap-around letters are not used in cursive writing. Children delayed in developing directionality typically make a continuous pattern. Often this motor behavior has no developmental basis but is a carry-over from forming manuscript letters incorrectly at an earlier stage. Children tend to generalize this pattern to the Clock Climber group. This needs to be corrected immediately.

INTEGRATION OF THE DIAGONAL WITH SPACE RELATIONS-Children who have not developed perceptual-motor integration of the diagonal will compensate by stopping the top round stroke short of 1 o'clock or continuing the bottom stroke past 6 to 5 o'clock. This will set the pattern for a vertical excursion to 1 o'clock. Generally the child is unaware of his avoidance of the diagonal. A clock face design is a valuable aid for teaching this group. It gives spatial reference for all the rounded segments and the child should sub vocalize as he practices.

EYE HAND COORDINATION-Children slow in developing motor proficiency usually benefit from being coached as to the ideal speed at which to perform an action. Graphic learning can be facilitated by guiding the novice writer when to move his pencil quickly and slowly. Once the child can visualize the progression of the letter, he should be coached to make a speedy lead-in as he curves up and over to 1 o'clock. This will facilitate kinesthetic learning and reduce the tendency to "draw" the letter using a visual-motor approach.

GROUP: KITE STRINGS

PERCEPTUAL MOTOR INTEGRATION OF THE DIAGONAL-Children delayed in this area will want to move up from the writing line with a slower vertical stroke rather than a faster diagonal strike. It will help to have the class visualize the difference between the way a helium filled balloon and a kite behave when held on a string. The balloon goes straight up from the hand but the kite swoops away from his hand. To encourage more slant visualize a stronger wind. DIRECTIONAL CHANGE IN CONTINUOUS FLOW PATTERNS-Children who are not well integrated have difficulty changing direction in a line flow pattern. In this group "r" and "s" require abrupt shifts in direction. Stopping at the starred points allows time for visual-motor reorganization so that the necessary shifts can be made precisely. If this teaching step is included, children will have success with these demanding letters.

GROUP: LOOP GROUP VISUAL MOTOR INTEGRATION OF THE DIAGONAL--Letters "h," "k" and "b" require an obtuse angled lead-in to allow room for the down stroke to cross at the middle marker as it continues diagonally downward to the writing line. The down stroke also must slant left toward the starting point. Letters "f," "1" and "e" require a less obtuse angling of the lead-in because their down stroke crosses the lead-in at a lower angle. SPACE RELATIONS--Children weak in perceptual-motor skill have difficulty starting to loop as they approach the top of the line. Their tendency is to touch a point before changing a movement progression. The sophisticated level of skill in the upward and reverse turning loop group is best achieve by having the class complete many repetitions of the motor pattern using isolated shoulder movements. DIRECTIONALITY--After the over-the-top stroke is rounded from 1 to 12 o'clock across the top of the line, it is best to pause before slanting left back to the writing line. This will help correct the natural tendency to continue into right down space.

GROUP: HILLS AND VALLEYS SPACE RELATIONS--Children need to be shown the subtle but slightly larger angle of the lead-in stroke compared to the down strokes in the main part of these letters. Children benefit from a visual guide to make multiple units of letters with equally spaced parallel lines. Looking back at the first down stroke in "m", "v" and "y" will help to keep the spacing uniform rather than become wider with successive units of the letter.

HANDWRITING FOR ALL STUDENTS

Functional handwriting must be taught more efficiently, thoroughly and permanently to all school children. This includes the great number of subtly delayed students who have trouble mastering a functional level of graphic skill to function comfortably in school and life. Developmental delays such as incomplete bilateral integration, organizational, memory, analytical and or perceptual motor output should be accommodated for with specific compensatory teaching techniques. With compensatory tips, all students should be expected to learn to write legibly in an integrated classroom setting. Manuscript before cursive may have a number of negative factors that hinder developing speed and kinesthesia for effective cursive handwriting. I) The paper is typically positioned square to the desk edge (except for D'Nealian) rather than on a slant to utilize the efficient diagonal draw of the wrist flexors for down stroking. 2) Manuscript techniques require mentally separating letters into their many line units and then joining the line units into letters. This demand is beyond the ability of children with part-to-whole perceptual motor or spacing problems. Cursive writing requires learning letters as whole motor units. 3) Many manuscript letters (including 12 capitals) have diagonal line(s). This is the hardest line orientation to produce and prevents mastery for many youngsters at the age when manuscript is customarily taught in our schools. Cursive writing avoids the most difficult diagonal where the line unit moves into (L) downward space 4) Spatial confusion is compensated for in cursive letters where all lower case letters lead-in from the writing line and move up into right space. With manuscript, spacing is required between each letter and each word. In cursive, spacing is reduced to between words. 5) There are no mirror image letters in lower case cursive formations. "b and d" and "p and q" output confusion is eliminated. 6) Children with right hemisphere spatial difficulties, known to be more rigid in their learning style, have a perplexing task in shifting to a new writing system. Most of these children will have struggled with but never really mastered manuscript in the first two to three years of school. Making such a shift is often beyond their tolerance. Frequently these students will revert to less efficient manuscript when task demands are high. Mixing the two letter systems is also a common finding. Educators would be sensible to wait for developmental readiness for graphic skills to develop before formal instruction for paper work is expected. Curricula that use instructional techniques to accommodate for perceptual and motor delays and deficits should enable nearly all students to advance to cursive writing at an earlier age. Second grade is the optimal time for most children to learn cursive handwriting. Student interest is high, and typically students have not yet acquired faulty habits of inventive cursive before formal instruction begins. Training activities of combining letters into simple two- and three-letter words to practice letter formations and connector units are at a more appropriate level for second graders. Initiating cursive/instruction in the fall of second grade allows a full year for students to stabilize this motor learning and be prepared for the higher volume of written work expected at the third grade. At this age, if cursive is enthusiastically taught, it can be enthusiastically learned. Dysfunctional writing with its misery and frustration should become obsolete.

PENCIL GRIPS The pencil must be held in a manner that provides both stability and mobility. Speed, axial force and control, pausing and endurance while writing can be influenced by the way the writer grips his pencil. Early and extended amounts of time "writing" before that have developed adequate stability in their hands, established a dominant hand, or learned the names of letters they are trying to copy. Through trial or error experiences with markers, crayons, and pencils some grips will become very efficient, others will become very inefficient. Benbow (1987) and Schneck (1991) found more inefficient grips among typically developing girls, than boys in schools in the Boston area. OPTIMAL TIME TO TEACH CURSIVE HANDWRITING At the beginning of second grade seems ideal in that: 1. Student interest and motivation is high.

2. Students will not have acquired the faulty habits of "inventive cursive" before formal instruction.

3. Training activities of combining letters into simple two and three letter words to practice letter formations and connector units are at a more appropriate cognitive level. 4. Timing will allow a full school year for students to stabilize this motor learning and be prepared for higher volume and cognitive level of written work expected in third grade.

CURSIVE WRITING BENEFITS 1. Movement patterns lend themselves to more automatic or kinesthetic motor learning. 2. Reversals and transpositions are less likely to occur. 3. Connected line enables learning words as units. 4. Production is faster because the multiple stops and starts and re-orientation of line segments are eliminated for each letter. 5. The motor patterns for letters and frequently used words will be established in his kinesthetic memory with extended practice.

COMMON HANDWRITING PROBLEMS CAUSES AND SOLUTIONS I. Difficulties with the loops that drop below the writing line. Evaluate tracking into downward space using the "Observation of Visual Motor Orientation and Efficiency" sheet. Pause at middle marker below the writing line. Move the writing paper higher on the desk. Develop kinesthetic sense for down stroke distance. II. Failure to close round letters. Evaluate all rotary joints - 1) supination at the elbow, 2) thumb carpometacarpal abduction with medial rotation and 3) metacarpal arching with index metacarpal phalangeal rotation.

a) Increase range of motor in supination. b) Increase range of motion and stabilization at file CMC joint of the thumb. c) Develop arches in the hand and rotation at the MP joint of the index finger.

III. Incomplete retrace before the release stroke Emphasize the rule that all letters lead-in from the writing line. Therefore one must retrace all letters except (b, o, w, and v) to the writing line to properly initiate the lead-in for the succeeding letter. BEAUTIFUL BUT NON-FUNCTIONAL HANDWRITING OBSERVATION: Well formed letters that are meticulously written. Writing speed 2-5 times slower than classmates. PARENT REPORT: "My bright child's hand cannot keep pace with his thinking. It is the only difficulty he has with school work." TEACHER COMPLAINT: "Child has good ideas but he can't get them down on paper." When asked to hurry up, the writing becomes totally illegible. "He cannot even read his own class notes". LEARNING PROBLEM: Writing has not been mastered to the automatic kinesthetic level. The writer became stuck using the visual / motor strategies initially taught, Visual guidance of the writing fingers is far too slow when output volume increases during mid-third or fourth grade. The student falls behind in his work when paragraphs or pages of written work are required. Dx: Based on evaluation of the following writing samples: A) The child should write a lower case connected cursive alphabet with eyes open. B) The child should write a lower case connected cursive alphabet with eyes closed.

a) Identify the "Think Breaks" in both samples. {These are darker line interruptions seen in the connector(s) preceding the letter(s) the child has to pause to motor plan}.

b) With vision diverted, can the child visualize the letters and write them using his kinesthetic sense?

c) How are the samples different / similar in appearance? d) Which sample flows better? If sample (B) is better, a visual-motor evaluation is in

order. Rx: Kinesthetic reinforcement of letters by groups: 1. Determine the group(s) where sluggish letter(s) are found.

2. Re-examine the line progression (motor plan) of the initial letter of that/those groups. 3. Write the initial letter of each problem group using visual guidance with verbal support. 4. Close eyes to visualize that initial letter. Using verbal support for the line progression, write the letter 15 times on scrap paper before checking results. 5. Evaluate the 15 repetitions of the letter for accuracy and circle all letters that are correct.

Star the very best one. The child now has his own kinesthetic pattern to reinforce to a functional level.

6. Once the initial letter of a slow group(s) is mastered without vision at a functional speed, bring the remaining letters up to speed in the group sequences illustrated in Loops & Other Groups.

7. The goal for a mid-fourth grader should be to write lower case alphabet in 24-30 seconds with ease. {Mid-fifth 20-26; mid-sixth 16-22 seconds}.

Motivational Tips: Have the student practice while "watching" TV. Practice should be done on worthless scrap paper such as old paper bags from the local grocery store. Process not product is the goal of this intervention.

THE WAY TO GO! KINESTHETIC APPROACH TO HANDWRITING

Functional handwriting must be taught more efficiently, thoroughly and permanently to all school children. This includes the great number of subtly delayed students who have trouble mastering a functional level of graphic skill to function in school and life. Developmental delays such as incomplete bilateral integration, organizational, memory, analytical and or perceptual motor output skills should be accommodated for with specific compensatory teaching techniques. Employing compensatory procedures, all students should be expected to learn to write legibly in an integrated classroom.

It is evident today that many students fail to naturally advance from visual motor learning visual motor programs. Techniques taught in traditional writing curricula, to the automatic! kinesthetic level of motor competence required for cursive script. They become "stuck" in drawing letters taught in

When writing output demands increase about mid-third grade, the written work of these students will deteriorate. The visual system will no longer be efficient enough to monitor the fingers as they manipulate the pencil to form sentences and paragraphs. The typical solution to 'slow down' will improve legibility but functional speed will be compromised.

Cursive handwriting is a kinesthetic skill. Therefore the ideal way to teach handwriting is with kinesthetic teaching strategies. Direct kinesthetic steps to teaching handwriting leaves nothing to chance in developing writing skill to its highest level. From the first teaching session, kinesthetic skills are practiced, integrated and evaluated as each letter is mastered. Kinesthesia, the sensibility of body position, movement, and weight is enhanced when a movement is repeated to the automatic level with vision averted. The 26 lower case letters in our alphabet can be reduced to four movement groups determined by their lead-in stroke. The four lead-in strokes can be visually associated with common objects in the child's world. Kinesthetic reinforcement focuses on the "feel of the motion" from the skin, joints and tendon receptors, and muscles to position, direct or correct letter progression. Teaching steps require the student to simultaneously visualize and verbalize the line progression for entire letter as he writes it in the air with eyes open and later closed. When able to visualize, verbalize and move his pointed fingers through the letter sequence in the air, he repeats the same progression on practice paper. The verbalization for each letter is the "motor plan'. The initial letter of each group must be over learned to the automatic/kinesthetic level so it can be modified for the remaining letters in the group. Practice of any letter within a group will reinforce mastery of the entire group. This makes kinesthetic motor learning very efficient. Essentially all second graders can master the lower case alphabet in six weeks if they practice thirty minutes each school day. Permanent integration of the lower case is usually achieved in 2-3 months. During the interim period before capitals taught, manuscript capitals should be used in combination with the lower case cursive letters for all classroom work. In this way, novice writers will be less likely to mix upper and lower case letters. When a student has achieved kinesthetic mastery of the lower case alphabet, he should undertake learning the capitals grouped for kinesthetic efficiency as well. Essentially all children learn to write more expeditiously using kinesthetic techniques. However these techniques are an added blessing to students with inadequate memory for configuration and perceptual motor problems; including integration of the diagonal, part-to-whole integration, crossing the midline confusion, and spacing problems. Kinesthetic techniques limit visual demands to the initial analysis of the line progression for each letter. Visual monitoring of writing should be limited to the placement of words on the writing line, accurate retraces and spacing of words. Motor learning at the automatic/kinesthetic level will gradually become more proficient without reduction in quality because it "feels' right and the writer secure. Kinesthetic motor learning is most permanent as it effortlessly moves to the level of implicit memory. Kinesthetic learning techniques are intriguing to practice. Averting vision reduces stress while increasing enjoyment. Youngsters are enlivened to become skilled at penmanship. Kinesthesia eliminates the drudgery of learning this much needed but neglected skill.

A NEUROKINESTHETIC APPROACH TO HANDWRITING

KINESTHESIA TRAINING ACTIVITIES Kinesthesia is the sensibility of body position, movement, and weight. Vision must be averted to evaluate and to facilitate training of sensory input from the skin, joints and tendon receptors, and muscles to position direct/correct motor performance. Weighted cuffs or heavy objects, deep rubbing or brushing, quick slapping or tapping of body parts can be used to increase kinesthetic awareness when a person receives too little sensation from the body receptors. Kinesthetic skills naturally develop in normal children. When a child experiences visual spatial delays or deficits, kinesthetic intervention is often preferable to visual motor training. Skills developed kinesthetically such as riding a bike, touch-typing or handwriting are most permanent. Awareness that a movement feels right will reduce the need for visual monitoring of a body part(s) in space while enhancing motor confidence and speed. For more information and demonstration of various kinesthetic training activities, refer to the video "Kinesthetic Fine Motor Activities," by Mary Benbow, available from Clinician's View. 1. MAGNETIC STICK FOR VISUAL TRACKING: (standing or seated) The child horizontally holds the tracking card with his non-dominant hand to guide a metal object along a printed track. He guides the metal object by sliding a magnet (glued to one end of a stick) from beneath the card track. The magnet stick should be held in a tripod posture with the dominant hand. Start by guiding a flat metal object (paper clip or safety pin) that requires less exact supination. Advance to guiding a tiny metal ball whose tangential contact demands maintaining the magnet stick in precise supination. 2. KINESTHETIC DROPPING/CATCHING: (standing or seated) Flex elbows to 90 degrees. Fully supinate the lower arm and pronate the upper arm. Drop a weighted object (rock, golf ball, ping pong ball) from upper to lower hand. Grade the activity separating the hands further apart and using lighter objects. 3. OBJECT PLACEMENT SENSITIVITY: (seated at a desk or table) Place a small object (coin, cube, or toy) anywhere within the arc of the arm's reach, Withdraw the hand to a side resting position, close your eyes and reach directly to retrieve object. Grade this activity by placing the object with one hand closing your eyes before reaching with the other hand. 4. DISPLAYED OBJECT SENSITIVITY: (seated or standing) Initially the child touches specified location (colored state on a U S map, object within a picture or illustration, number on a calendar pad etc.). After returning his hand to a side resting position, he closes his eyes and touches a specific object. Grade by visualizing the hand moving to the named object before closing your eyes and placing your finger on the specified object. 5. ALTERNATE STACKING: (seated at a desk or table) Pile several like objects (checkers, poker chips, plastic discs etc.) of two different colors to the (R) & (L) of midline within the working area. With eyes closed, the child builds a tower with alternate hands to create a striped effect. Unstack the tower to each side pile.

6. TARGET SHOOTING: (seated or standing) Gather (6-10) objects of the same weight and size to be pitched into or at a target. With eyes open, the child practices long enough to gain the feel of the position and power required to hit the mark. Without altering his or the target position, he shoots for the goal using his kinesthetic sense (Eyes Closed). 7. HOOPS OVER THE CONE: (seated on a one-legged stool or vestibular ball) Gather (6-10) 12-15 inch plastic hoops of the same weight and size to be pitched over a cone. Seat the child and have him press the hoops between the palms of his hands (no thumb or finger use) with elbows extended. The child sights the cone through the center of the hoop. When the hoop is properly centered, he flexes his elbows and pitches the hoop over the cone. With eyes open, practice to gain the feel of the position and power to hit the mark. Without altering his or the target position, he shoots for the goal using his kinesthetic sense (Eyes Closed). This same learning sequence can be used with dart type games as well. 8. CHALKBOARD DESIGNS: (standing at chalkboard) Draw a vertical line from top to bottom on the chalkboard. Position the child with the line at his midline. With a piece of chalk held in each hand, he should draw a series of symmetrical lines radiating from the midline into his peripheral space. Start high and work downward or low, then work upward. Use straight, over curves, under curves, loops etc. Continue or repeat the sequence without vision. Grade by becoming faster and more rhythmical, uniform, and accurate. 9. CHALKBOARD DESIGNS: (standing at chalkboard) Repeat the above sequences with the lines starting at periphery and moving to midline. 10. BUTTERFLY CHALK DESIGN: (standing at chalkboard) Place the following numbered pattern for the child to repeat for the butterfly. Have him touch his nose to the chalkboard to locate #2 dot. The #1 dot should be 8-10 inches below the #2. The #3 positions are determined by asking the child to reach up and out as far as comfortable with each hand. Place the #3 dots at these positions: Holding a piece of chalk in each hand, the child draws double lines from #1 to #2, separates upward and outward to the #3 dots before returning to #1 to repeat the sequence. Once he has the feel of the pattern, he should close his eyes and continue the pattern several more times. Finish by adding feelers after passing the #2 dot. 11. CLOCK ORIENTATION: (standing at chalkboard) Have the child touch his nose to the chalkboard to locate the middle of the clock position. Mark it with a dot. Using two pieces of chalk he should draw clock hands from the center to symmetrical positions on the imaginary dock face - 12 & 6; 3 & 9. 1 & 7 etc. Grade by having the child draw clock hands from the periphery toward the clock center. Repeat these sequences without vision. 12. CHALKBOARD SPORTS: (standing at chalkboard) Sports that have a spatial component (baseball diamond, golf green) can be sketched on the chalkboard. After the child traces the diagram and motorically senses the size and shape of the display, he should be able to close his eyes and draw a run with chalk from home plate for a single, double or home run. Grade by having him visualize another display and close his eyes to hit a specific numbered hole in golf. 13. MIRROR IMAGE DESIGN: (standing at chalkboard) With a piece of chalk in each hand, a primary child will delight in his success in drawing hearts, apples, houses and diamonds etc.

14. LINEAR MOVEMENT DESIGNS: (standing at chalk board) This activity should be introduced after confidence is gained with the bilateral designs. The child should work in a (L) to (R) progression slightly above eye level. Any basic shape or letter can be repeated in this fashion. The child should develop uniformity, fluid repetition and speed before closing his eyes for kinesthetic practice. 15. HANDWRITING PRACTICE: (standing at chalkboard) Handwriting on the chalkboard is a welcome alternative to paper pencil practice. It is beneficial in reducing hand fatigue and enjoyable for novice writers. Once a letter is written well with eyes open, it should be written with eyes closed to verify if the hand "knows" how to write the letter. This exercise is an effective technique to increase speed in writing. 16. MYSTERY WRITING: (standing at chalkboard) After the child has mastered a few letters, this game can be used. The novice writer holds a piece of chalk in his writing hand and closes his eyes. An experienced writer guides his hand, which is holding the chalk, and writes a letter or short word on the chalkboard. The child has to identify the letter or word from the movement he sensed before checking the evidence. WHY KINESTHESIA? 1. Handwriting is a kinesthetic skill. The best way to teach handwriting is with kinesthetic strategies. Not all students will naturally advance from visual motor learning techniques, taught in traditional writing curricula, to an automatic/kinesthetic level of motor competence in cursive handwriting. Many students get "stuck" and continue to draw letters following visual motor procedures originally taught. 2. Kinesthetic motor learning is very efficient. Almost all second graders can master the lower case alphabet in six weeks if they practice thirty minutes each school day. Permanent integration of writing the lower case letters should be achieved in 2-3 months. During this interim period, manuscript capitals should be used in combination with the lower case cursive for all classroom work. When kinesthetic mastery of the lower case is accomplished, a student should progress to the capitals. In this way, novice writers will be less likely to mix upper and lower case letters. 3. Kinesthetic teaching strategies require the student to simultaneously visualize and verbalize the movement pattern. The 26 lower case letters in our alphabet can be reduced to 4 movement groups based on visualizing common objects in the child's world. The initial letter of each group must be over learned to the automatic/ kinesthetic level so it can be readily altered for the remaining letters in the group. Practice of any group letter will reinforce mastery of the entire group. 4. Kinesthetic teaching steps reduce visual demands to the analysis of the line progression for each letter. Visual motor guidance of writing should be limited to accurate retraces, spacing of words, and the placement of words on the writing line. 5. Kinesthetic writing reinforcement focuses on the "feel" of the movement patterns. Kinesthetic practice is most advantageous to students with inadequate memory for configuration and perceptual motor problems; including integration of the diagonal, part-to-whole integration, crossing the midline confusion, and spacing problems.

6. Motor learning at the automatic/kinesthetic level will gradually become more proficient without reduction in quality. 7. Kinesthetic motor learning is most permanent as it efficiently moves to the level of implicit memory. 8. Kinesthetic learning techniques are intriguing to use. Visualizing the formation and movement pattern of a letter powerfully reinforces motor learning: Averting vision effectively reduces stress. Kinesthetic practice is fun so youngsters are enlivened to become skilled at penmanship. WORKING TERMINOLOGY The following concepts are based on Loops and Other Groups, by Mary Benbow, available from OT Ideas. Line: Use spatial terms as they relate to the writing line. The dotted middle marker above the writing line indicates the highest level for 1/2 space letters. The dotted middle marker below the writing line indicates the lowest level for the seven-drop loop letters below the writing line. The top or head line indicates where full space letters reach above the writing line. In order to learn the "feel" of vertical proportion of each letter, the student should fill the indicated spaces. Starting point: All lower case letters begin on the writing line to the left of the letter. This location should be marked with a dot. The student should initiate the lead-in from the dot but not copy it. Lead-in stroke: The lead-in stroke pattern determines each letter's group placement. The lead-in of the four groups: a) climb, b) slant, 3) loop or 4) follow an overhand curve according to their common formations. Initially, optional lead-in strokes should be taught because they become the connectors for the subsequent 1etters. Lead-in consistency helps control the letter formation while reducing memory demands. Retrace: These are the line units where the first stroke is traced over in order to move to a new position to continue the letter. For example, one retraces the lead-in in the letter "a" between 1 and 9 oclock before continuing down to complete the letter. Twenty-two letters have a retrace unit. Release or Lead-out stroke: Twenty-two lower case letters return to the writing line before curving up or continuing on to the new letter. GET READY: THE LEARNING SETTING Properly fitted furniture for all students. A) Chair height should allow firm contact of child's heels on floor for weight shifting as the writing arm moves horizontally away from his midline as the writing moves across the page. Knees and hips should be flexed at 90 degrees. Weight should be evenly distributed on both hips.

B) Desk height should be 2 inches above the writer's bent elbow when child is seated on a properly fitted chair. If the desk is too high, it will ABduct the shoulders too widely for maximum control of the hands. If the desk height is too low, the child will be inclined to support his head rather than support and adjust his writing paper. C) Every desk should directly face the chalkboard where letter analysis and demonstration will be performed by the instructor. Facing forward will reduce direction and positional confusion. GET SET: STUDENT PREPARATION FOR MOTOR LEARNING A) Every teaching session should begin with each child assuming a symmetrical position to write. Children who lack postural sensitivity fail to make the rotary trunk adjustments to counter balance posture. In most cases the child is unaware of his postural situation, so the instructor should cue rather than criticize him to shift his weight evenly on his chair. Holding one's body in a comfortable, stable sitting posture is crucial for learning to write kinesthetically. B) Paper slant. The slant of the paper should run parallel to the line of the writing arm when the hands are relaxed and together at midline on the desktop. A piece of masking tape can serve as positional jig until paper alignment is automatically assumed. C) Upward paper adjustment should be taught as the writing progresses down the page so the writing hand remains below the writing line at all times. INSTRUCTOR'S GUIDE The instructor draws a 15-inch model of the letter on the chalkboard carefully positioned within a three-unit divided line. This model is used to teach the following: a) Starting point should be indicated with a dot to left of letter position on the writing line. b) Analysis of letter position within the 1/2 space vertical line units to be filled. c) Discuss lead-in group assignment and reinforce visualizing the entire movement of the letter to be learned. d) Demonstrate and verbalize the whole stroke progression using consistent terminology. Encourage each child to "talk to your hand" ( the motor plan ) and make your writing hand do exactly what you are telling it to do. e) Single line units should be made using quick flowing strokes, and retraced segments should be slowed to allow visual guidance of the pencil. f) Negative shapes are produced by the writing line and the letter stroke(s). This will be useful in helping children self-correct their letter forms. g) Note and number the places each letter makes contact with the writing line, middle markers or head line. h) As additional rules are required for certain letters, they should be taught as part of that motor plan. STUDENT'S MOTOR LEARNING a) Students point their index and long finger while holding down digits 4 & 5 with the thumb of their writing hand. While joining the verbal support recited by the instructor for the movement pattern, they "trace" the chalkboard model letter in the air using isolated shoulder movements.

b) While tracing the letter in the air, the students should gradually try to visualize the stroke