Grasp patterns in the pediatric special education setting

Grasp Patterns in the Pediatric Special Education

Setting

By Jennifer Phillips, OTS, COTA/LSpring 2013

Movement in Context

Grasp Patterns, Grip, & Pinch, A Brief Review.Why is grasp important? Grasp patterns affect

how our clients interact and learn within their environments and can influence the levels of independence our clients achieve in occupational tasks.

Grasps with NO thumb opposition include hook grasp, power grasp, and lateral pinch.

Patterns that require thumb opposition include tip and palmar pinch. Tip pinch includes pincer and 3 jaw chuck, or tripod as it is more commonly called in the school setting. Tripod is also sometimes referred to as

Review of Grasp Patterns, continuedPalmar prehension (Clarson and Gilewich, Belkin and

English 1996, cited in Coppard-Lohman, 2007 p.63) Other grasp patterns that require thumb opposition are

cylindrical grasp, spherical grasp, and intrinsic plus grasp (however in the intrinsic plus position the thumb is positioned in palmar abduction with opposition with the third and fourth fingers, as would be required to eat a hamburger or grasp a book (Belkin and English, 1996, cited in Coppard and Lohman, 2007, p. 65).

A common therapy misconception when working on fine motor skills in children is that there must be proximal control in order to establish fine motor control, and the degree of proximal control is NOT correlated with distal control (Case-Smith, 2005)

Review of Grasp Patterns, continued…AND a little neuro review!This misconception is common, as postural control is

developed in a cephalo-caudal fashion (proximal to distal, head down) This is because two motor systems are used for upper extremity control (Pehoski, 1995, cited in Case-Smith, 2005) The system that is responsible for proximal control and head control is the ventro-medial brain stem pathway that synapses with interneurons to trunk and proximal muscles, in contrast to the corticospinal system that originates in the primary motor cortez and directly synapses with motor neurons in the hand muscles, allowing for isolated finger movements. (Pehoski, 1995, cited in Case-Smith).

Pincer Grasp (a.k.a the “cheerio grasp)Between 9-10 months of age,

children are able to hold a small object between the thumb and radial fingers.

At this stage of development, intrinsic muscles are not developed, so there is little inhibition of the ulnar fingers. (Case-Smith, 2005)

I would estimate that 70% of the school aged children I worked with (7-15) present with decreased intrinsics and “flaring” of the ulnar side fingers when performing fine motor tasks.

Food based activities are usually motivating!

Cylindrical GraspMost typically developing

children are able to use a cylindrical grasp with control between 18 months and 3 years (Case-Smith, 2005).

Thumb opposition as well as finger adduction or abduction (depending on the size of the cup) are required.

Children with difficulty maintaining this position will benefit from a strengthening program and Sippy cups when practice with an open cup is not feasible .

Spherical GraspDevelops around 18 months to

3 years of age (Case-Smith, 2005)

Requires fingers abducted while object rests on the palm.

In establishing this grasp, consider the arches of the child’s hand may be underdeveloped. Smooth balls are frustrating for many children with delayed visual motor, motor planning, and grasp problems. Consider tactile balls, light ups balls, and small stuffed animals (such as angry birds) may be less threatening. Always consider tactile defensiveness as a possible problem .

The Tripod or 3 jaw chuckVery important for

handling a variety of tools, pencil, fork, paintbrush.

Typically develops by 3 years of age but children may not be consistent with until 5-6 years of age.

Thumb opposition allows for greater objects control and visual regard of the object. (Case-Smith, 2005)

A boy with pinch difficulty…Prior to snapping photos I had repositioned Elmo multiple times into radial side fingers as the boy

utilizes power grasp, & compensation with his palm. Just when I had given up and thought it was a good time to get pictures of grasp

difficulty he has some success!!! See below…Note slight extension of ulnar fingers in photo 1Power grasp on Elmo in photo 2

A boy with pinch difficulty continued…Notice he is assembling without regards to body

orientation of Elmo.Difficulty with grasp comes from sensory difficulties and

tendency to use fine motor objects for visual stimulation as in photo 2.

Lateral PinchLateral Pinch is the strongest of all tip prehensions. (Coppard and

Lohman,2007 ) Keys can be motivating, especially when the goal is to unlock something

desired, such as an iPad or a treasure! Animal hospital is a classic OT toy for working on lateral pinch.

In my current special school setting, although pencil grasps and cutting are worked on, our emphasis is on ADL such as dressing, hygiene, and community integration. However, here are some

common grasp problems seen in the school setting.

Other Considerations when assessing and thinking about grasp…. In hand manipulation skills, does

the child have them? Does their f.m skills reflect their

overall level of developmental skill?

Are they able to use B.I? Are they able to stabilize their

forearm against gravity? Do they have adequate wrist

movement? Is diagnosis a factor in limitation

of available movement, as in CP? Are there retained reflexes that

are impeding movement as a whole?

Does the child have the cognitive capability to do this task?

Are visual perceptual skills impacting fine motor?

WHAT ABOUT VISUAL ATTENTION?

How about tactile defensiveness, OR ability to discriminate touch?

Can I use something norm referenced like the BOT, or clinical observations combined with developmental milestones to assess?

How meaningful is this task for future skills and independence?

Does the child have adequate visual support to understand what I am asking him/her to do?

When assessing grasp, it is very complicated, beyond the pattern itself. I will leave you with a few fave activities and a HEP for your clients! Trapeze for thumb opposition, “Octopus game” for 3 jaw chuck. I have cards with visuals that also work on social and g.m

skills. Lower functioning children can just either put on paper fish or baby Octopi, or simply help to release the clothespin. Beware

compensatory movement with putty!

Treating grasp in the special school setting…

Most kids have grasp difficulty in my current setting.

The great thing about the setting is the emphasis on ADL and early practice with skills.

The downside is that although, it really is educationally/program based vs. sensory integration approach. Some children would benefit from a more sensory approach.

In our setting we utilize containers of all kinds and baggies to work on grasp skills. We use clear containers and place motivating items inside.

References:Case-Smith, J. (2005) Occupational Therapy for Children.

(5th Ed.) St. Louis, MO: Mosby-ElsevierCoppard, B. & Lohman, H. (2007) Introduction to Splinting:

A Critical Thinking and Problem Solving Approach. (3rd. Ed). St. Louis, MO: Mosby-Elsevier.