Week 6: Addressing fine motor & Visual Motor barriers to occupational performance

components of hand skills

•Reach: Extension and movement of the arm for grasping or placing objects

•Grasp: Attainment of an object with the hand

•Carry: Transportation of a handheld object from one place to another

•In-hand manipulation: Adjustment of an object in the hand after grasp

•Bilateral hand use: Use of two hands together to accomplish an activity

•Voluntary release: Intentional letting go of a handheld object at a specific time and place

Factors that contribute to hand development & Function

Hand skills

• Social & Cultural Factors

• Sensory 

  • Somatosensory functions

  • Sensory integration

  • Visual Perception

• Musculoskeletal Integrity

  • Scars/wounds

  • skin integrity

  • ROM

  • Strength, tone

Neuromaturation theory

General sequence of motor milestones; development is pre-programed; motor development driven by the CNS & primitive reflexes considered building blocks of development

Dynamic Systems Developmental Theory

Each child has a unique development trajectory widely influenced by the affordances available in their environment

The Progression of Reach

Once infants can reach, they work on dissociating the 2 sides of their body or unilateral reaching

Bilateral arms movements are the predominant patterns of movement throughout the 1st year of life

They refine unilateral reaching so that they are using less abduction/internal rotation and are doing more purposeful hand opening and begin to use shoulder flexion

Finally, babies are able to reach with trunk rotation, full elbow extension, slight forearm rotation, and wrist stability

Typical Trajectory of Hand Skill Development

Primitive and transitional grasps

Purposeful grasp

Automatic release

Purposeful release

Coordinated bimanual skills

Picture this as a continuum more than a hierarchy

Primitive & Transitional Grasps

Initially the infant’s fisted hand is due to the predominance of physiologic flexor tone that dominates upper and lower extremity movements

In the first week, the grasp reflex has not emerged

Grasping reflex

First seen at week 2-4

Infant will close fingers around an object placed in palm

By week 8 there we see 2 phases of this reflex

• Catching phase (immediate flexion of fingers & thumb)

• Holding phase

Grasp

The grasping reflex lays the synergistic foundation for grasps. The first grasp to emerge looks like the grasping reflex

Palmar grasp (0-5 mos.)

• Fingers flex around object and press into palm

Ulnar palmar grasp

• Used to think this came first. Research indicated that index finger is active first

Radial palmar grasp

Fractionated grasp: at 4-6 months one to two fingers begin to flex in isolation from the others

Different types of Grasp

• reflexive

  

• palmar

  

• radial palmar

  

• ulnar palmar

  

Raking Grasp (7-8 months)

vReaching for and grasping a small object using a raking motion

vAll of the fingers flexed at the IP joint

vHand may need support from a solid surface to be successful

Radial Digital Grasp (8-9 months

Thumb opposition to the radial fingers

Object is held proximal to the pads of the fingers with space visible between the object and the palm

Object is held away from the palm, giving the child greater manipulative control. Yet, this grasp is not a fingertip grasp, because the object is held proximal to the pads of the fingers

Inferior Pincer Grasp (8-9 months)

Object being secured between the adducted thumb and radial side of the flexed index finger

The thumb is not opposed, but slides over in a pattern of adduction to trap an object against the side of the index finger

Pincer Grasp (10-12 months)

Object being held between the opposed thumb and pad of the index or middle finger

No longer needs external support to successfully grasp an object

Three Jaw Chuck (10-12 months)

•Thumb opposition to the index and middle fingers

•The object is held at the pads of the index and middle fingers, as well as the pad of the thumb

•The IP joints of the index and middle fingers range from extended to slightly flexed, with flexion of the MCP joints

•To oppose the digits, the thumb rotates and flexes toward the fingertips

•The ulnar two digits do not participate in grasping the cube, but provide support to the radial side of the hand

Automatic Release

Reflexive behavior: Fingers extend as infant withdraws and abducts fingers

Avoiding reaction: When the dorsum of the hand is touched, the fingers abduct and extend

Purposeful Release

Infant transitions from automatic release to purposeful release around 5-6 months

By 6 months, baby can activate release for two-handed play or finger feeding

By 7 months, baby can transfer object from one hand to the other

By 1 year, child can grade hand opening

Evaluation of Hand Skills in Children

Screening for Hand Skill Problems

Evaluation content

1. Measurement of active and passive ROM

2. Evaluation of strength

3. Evaluation of tactile functioning

4. Assessment of posture

5. Administration of a standardized developmental test (including motor test, VMI test)

6. Assessment of hand skills in prevocational and work tasks

Guidelines for intervention

Setting goals: Occupation based; functional goal

Role of OTA: Consider the roles of OT assistant and others in intervention

Preparation:

• Positioning the child

• Improving postural tone and control

• Improving muscle strength

guidelines for intervention: Preparation: Positioning the child

• Optimal positioning

• Position to facilitate optimal movements

• Stable chair with adequate foot support

• Appropriate size chair and table for good posture

• Adequate support if posture is unstable

• Considering standing position while participating in FM tasks

guidelines for intervention: Preparation: Improving postural tone and control

• Upper extremity weight-bearing to encourage co-contraction

• Weight-bearing in prone position

• Use splints during weight-bearing

• Pressure on hand/palm to relax or stabilize

guidelines for intervention: Preparation: improving muscle strength

Strengthening programs

Use of neuromuscular electrical stimulation

Intervention: Preparatory Activities

OTs might have the child participate in a variety of preparatory activities

• Modulate muscle tone: activities increase, decrease, or balance muscle tone

• E.g.s- chair push ups to “wake up” the muscles, slow and rhythmic rocking from side to side (to relax high tone)

• Promote proximal stability & strength: activities that encourage stability of joints and strengthening of muscles

• E.g.s- animal walks, resistive band exercises, putty exercises

Little evidence to support their use without engagement in occupations

Intervention: biomechanical approach

Primary focus- improve ROM, strength/endurance, postural alignment, joint stability

Beneficial for children with musculoskeletal & neuromotor disorders

Intervention ideas using this model-

• Child’s postural stability (standers, wheelchair, side-lying, prone, supine, sitting, standing)

• Tools such as grippers, adapted pencils/markers, etc.

• Paper positioning/writing surface

Intervention: motor learning approach

Primary focus- to help achieve motor skills through practice, and experience

Beneficial for any child who can follow instructions & engage in repetitive practice

Examples of intervention techniques typically used using this model-

• Practice, mental rehearsal, feedback, reinforcement, error based learning

• P-CIMT

Research connection

• Evidence shows that children with DCD, CP and adults with brain injury benefitted from intervention that specifically used motor learning approach (Ketelaar, M., Vermeer, A., Hart, H., et al. (2003)

Since 2000, >50 studies published on the effectiveness of P-CIMT

• Evidence shows positive effects on hand function for children with unilateral CP

Intervention: sensorimotor approach

Primary focus- to enhance and reinforce motor learning by providing multisensory input through selected activities

Beneficial for any child who may not be motivated or frustrated trying to learn a fine motor skill

Examples of intervention techniques typically used using this model-

• Writing tools (e.g. felt-tip pens, scented crayons/markers, paintbrush, weighted pencil, vibratory pens, etc.)

• Raised lines or colored lines, thick margin on L side, etc.

• Practice writing on shaving cream, food, paint, etc

Research connection

• Not enough evidence demonstrating improved hand skills using sensorimotor approach

One study showed that children demo. improved handwriting performance with repetitive practice compared to sensorimotor interventions (Denton, P., Cope, S., & Moser, C., 2006)

Intervention: cognitive approach

Primary focus- to facilitate motor skill acquisition using highly individualized problem solving techniques

Beneficial for any child with cognitive limitations (however not limited to that!)

Examples of intervention techniques typically used using cognitive approach:

• Using mask to uncover 1 line at a time during FM task, pneumonic, colored lines, one finger space, tongue depressor, etc.

Research connection

• Cognitive strategies shown to improve handwriting when combined with “therapeutic practice” (Candler, 2019)

Hand function & writing

Based on the progression of grasps, there are 6 underlying components of handwriting

1. Upper extremity support

2. Wrist stabilization

3. Open and stable thumb web space

4. Stable arches of the hand

5. Radial-Ulnar dissociation (Separation of 2 sides of the hand)

6. Precise in hand manipulation

Upper Extremity support

Upper extremity support is required for handwriting because the proximal stability of the trunk, shoulder, elbow, and forearm allows the wrist and fingers to engage in tasks that require precise dexterity

Proximal stability/support promotes distal mobility/function

Wrist stabilization

Wrist position influences the position of the joints of the fingers and thumb, as well as overall performance

Optimal wrist posture for precise finger movements:

• Neutral with slight wrist extension

• Being able to maintain slight extension and a position in neutral allows the thumb to be aBducted and opposed to the fingers

Activities to facilitate wrist stabilization

Games that promote wrist strengthening like “Restaurant game”

Fun Gross motor exercises like “animal walks”

Using Vertical surfaces to promote wrist extension

Using toys and games promoting wrist extension such as “Ants in the Pants”

Functional activities such as help clean vertical surfaces or wipe whiteboard

Open & stable thumb web space

Point to your web space

This looks like the a-OK sign

An open web space allows for thumb and finger opposition

A stable open web space allows for optimal manipulation of objects

Hold your pencil as you normally do

• Is it resting in you’re a-OK space?

• If it is, you might be writing with a “closed” or “semi-closed” web space

vFM Activities to facilitate open webspace:

Beading Activities

• Finding beads in putty

• Threading beads

Lacing activities

Tweezer activities

Puzzles (Pegboard)

Arches of the hand

Grasp depends on the integrity of mobile units of the arches

The structure allow for the flattening & cupping of the hand

• Longitudinal arch: wrist to fingers

• Distal transverse arch: along the metacarpals of the digits

• Proximal transverse arch: along the wrist

• The thenar & hypothenar eminence use the instrinsic muscles for cupping & arching

• Underdeveloped arches could impact mobility- lead to decreased function

Activities to improve arch development:

Activities that facilitate intrinsic muscle strengthening such as playing with tongs

Squirt toys

Construction play such as playing with Legos

Playing with squish balls/hand fidgets

Radial-Ulnar dissociation

Radial-Ulnar dissociation is required for precise movements

Stability of the ulnar fingers allows for manipulation of objects with thumb & radial fingers

Ulnar digits assist with power

Radial digits are stabilized by ulnar digits for precise handling

Activities to facilitate radial-ulnar dissociation:

Squeeze spray bottle with 2nd and 3rd digits only

Games like “feed the frog” with waterbeads, cereal, coins, etc.

Hold on to a small object with last 2 digits while coloring

Tearing paper

Playing games like “Lite Bright” puzzles

Games like finger puppet or finger soccer

Playing with stickers

In-hand manipulation

Handwriting also depends on precise in-hand manipulations

It’s the adjustment of an object in the hand after grasp

Activities to facilitate in-hand manipulation:

Activities facilitating translation (palm-to-finger and vice-versa)

Activities facilitating shifting of fingers manipulating fasteners

Activities facilitating rotation such as flipping crayons for a different color, rotating bottle top

Handwriting grasp: primitive

Before 3 years

Pencil in palm, 5 fingers

Movement generated more from shoulder/elbow (whole arm movements)

Handwriting grasp: transitional

Between 3-6 years

Pencil held more distally (with less control)

Movement generated more from elbow/wrist (forearm movements)

Handwriting grasp: mature

After 6 years

Only using 3-4 fingers

Clear radial-ulnar dissociation

Movement generated more from wrist/fingers

OT’s Role in Supporting Handwriting Skills: Foundational Readiness Skills:

Postural stability, shoulder control

Fine motor skills (grasp, dexterity, bilateral coordination)

Visual-motor integration

Sensory processing (tactile, proprioceptive input)

OT Programs Used:

Learning Without Tears (previously referred to as HWT)

Size Matters

Common OT Interventions: (IMP TO KNOW WHERE TO START)

Play-based tasks, vertical surface work, tactile exploration

✏ Pre-Writing Skills: start here!

Vertical → horizontal → circle → cross → square → diagonal → triangle

Tools: dry erase boards, sensory bins, Roll-A-Dough letters

🔠 Uppercase First:

Easier due to uniform size, starting points

Focus on stroke sequence (top to bottom)

🔡 Lowercase Letters:

Taught in formation groups (Magic C, tall, short, fall)

Tools: use lined paper & visual supports

📝 Word & Sentence Formation:

Emphasize spacing, alignment

Scaffold: copy → dictated → original writing

🔄 Functional Goals:

Speed, legibility, and endurance

Use assessments, introduce AT if needed

OT’s ROLE: Enhance Visual Efficiency and information processing through structure visual tasks

Vision Components:

• Refraction:

  • Eye Health of structures

• Visual efficiency

  • Oculomotor

    • Fixation

    • Smooth Pursuits

    • Saccades

  • Accommodation

    • Sustain/Change Focus

  • Binocularity

    • Convergence

    • Divergence

• Visual processing

  • Discrimination

  • Closure

  • Figure Ground

  • Spatial Relations

  • Memory

Comorbidities

•Cerebral palsy

•Neurological insults or brain abnormalities

•Chromosomal abnormalities and genetic conditions

•Learning disabilities

•Cognitive impairments

•Prematurity and developmental delays

•Fetal Alcohol Syndrome

•ADD/ADHD

•Autism

•Sensory Processing Disorder

•Cortical Visual impairment

•CHARGE syndrome

Development of Visual Motor Integration (VMI)

•3 Months- Track rattle while lying on back

•6 Months- Extends arm to reach for the rattle

•9 Months- Move towards and reach for toy

•12 Months- Pick up and place cheerios

VMI is a specific motor skill that allows for coordination of visual input with a  corresponding motor response

Development of Prewriting

Scribbles on paper	10–12 months
Imitates horizontal, vertical, and circular marks	2 years
Copies vertical and horizontal lines and circles	3 years
Copies cross, right oblique line, diagonal left oblique cross, some letters and numerals; may write own name	4–5 years
Copies triangle, prints own name, copies most lower and uppercase letters	5–6 years

writing skills Development

Pre-K to 5th grade

Progression from LARGE to small

Progression from straight to curvy

Speed is a combo of motor skills and cognition

Progression from imitate, copy, draw from memory

Measuring Handwriting Performance

• domains of handwriting

• legibility

• writing speed

• ergonomic factors

Domains of handwriting

•Near-point copying

•Far-point coping

•Writing dictated words

•Composition

•Writing alphabet

•Legibility

•Alignment

•Spacing

•Size

•Readability

•Letter formation

vWriting speed

•Number of words per minute

•Consider within context of classroom, assignment, child

•Ergonomic factors

Posture

•Upper extremity stability

•Mobility

•Pencil grip

Assessments

•Beery VMI

•DTVP-3

•BOT-2

•TVPS-4

BOT-2

Fine Motor Precision

Fine Motor Integration

Handwriting Components

Legibility

Baseline Orientation

Alignment

Spacing

Size

Slant

Collaboration with Developmental Optometrist.

Role of OT

Screen for Visual Deficits

Refer to vision care Specialist for Evaluation and Diagnosis

Child may be recommended for Vision Therapy

OT can then develop appropriate compensatory & instructional strategies to facilitate access to school curriculum

Intervention: Oculomotor Skills

Central/Peripheral Vision, Pursuits, Saccades

Flashlight tag

Alphabet Tracking

Reading

Mazes, Connect the Dots.

Where’s Waldo/ I Spy

Consider use of equipment

Mirror

Distance

Spacing

Retained Asymmetrical Tonic Neck Reflex

Poor Reading Comprehension

Poor Visual Tracking & Eye Pursuits

Poor Handwriting

Poor Hand Eye Coordination

Poor bilateral coordination

Writing compensations: tight pencil grasp, turning paper, decreased fluency, extended arm, writing w/ slant, letter reversals

Intervention: Eye patching to improve Oculomotor Skills

Common treatment for Lazy Eye (Amblyopia)

Rec. 2-6 hours

Intervention: Oculomotor Skills: Marsden Ball

Intervention: Accommodation

Highlights – Find it

Spot it

Copying from the Board

Zingo

Shape Sorting Games

Stack and Sort Board

Bean Bag Toss

Any Reaching/Put in Task

UNO

Spot THE DIFFERENCE

Intervention: Eye Teaming

Consider Laterality, Bilateral Coordination, Convergency/Divergence

Pen in Cap game

Paper tearing

Arm and leg raises

Arrow Chart

Scissor Skills

Zoom Ball

Visual Perception Impact from Cortical Visual Impairment

Decreased Visual Attention and Visual Recognition

Decreased ability to use central vision

Compensation with Peripheral Vision

Drawn to bright lights

Prefer Objects Close to Face

Visual Motor Skills: Typing

•Text to Speech

•Electronic spell check

•Picture supported text

•Abbreviated expansion

•Word prediction

•Voice recognition software

•Large Print

•Zoom

•Display

Visual Motor Skills:Alternative and Augmentative Communication Devices

•Use of Keyguard

•# of icons per Page set

•Visual Feedback

•Display Contrast

•“Masking”

Key take away message

diff types of handwriting intervention

Intervention: Vision + Vestibular Systems