Transcript Development of Hand Skills_0x

Development of Hand Skills
BY KEUMSUN HWANG
Definition
• 여러 가지 쥐기 패턴을 사용하면서 다양한
물체들을 조작할 수 있는 능력
• Hand skill, Fine motor skill, Fine motor
coordination, Dexterity
• 여러 가지 쥐기 패턴을 사용하여 다양한
물체들을 조작할 수 있는 능력
2
Component of hand skill
• Reach
– Movement of the arm and hand for contracting an
object
– 팔과 손의 움직임
• Grasp
– Attainment of an object with the hand
– 손으로 물체 잡기
• Carry
– Transportation of object from one place to another
3
Component of hand skill
• Voluntary release
– Intentional releasing of object at a specific time and
place
– 의도를 따라 정확한 시간과 위치에 물체 놓기
• In-hand manipulation
– Adjustment of an object within the hand after grasp
– 잡은 후 손 안에서 물체 조작하기
• Bilateral hand use
– Use of two hands together to accomplish
– 목표를 성취하기 위해 양 손 함께 사용하기
4
Context factors
Social factors
Socioeconomic status
Gender & role expectation
Cultural factor
Client factors
Development of
hand skills
Postural
mechanism
Hand skills
cognition
Visual
perception
Effective use of the hands
Contribution of context factors to
hand skills
• Social Factor
• Cultural Factor
Contribution of context factors to
hand skills
• Sensory function
• Neuromusculoskeletal & movement-related
function
• General development consideration
Sensory function
• 감각통합
-Sensory regisstration problem
- Tactile hyper-sensitivity
- Poor tactile discrimination
- Dyspraxia
• 시지각과 인지기능
Neuromusculoskeletal &
movement-related function
• Function of joint & bone
- integrity of the hand: no congenital hand
anomalies
- Range of motion
• Muscle function
- Strength
- Muscle Tone
- Muscle endurance
General development
consideration
• Mass to specific
• Proximal to distal
• Ulnar--radial
• Palm-- finger
Reach
• Asymmetric pattern  midline 
dissociated movement
• Mature reaching: sustained trunk
extension & slight rotation
Grasp pattern 분류
(1) 장악력 유무
Prehensil movement
Precision Grasp
Power Grasp
Non prehensil movement
Pushing
Lifting
(2) 엄지사용 유무
Thumb opposition
Tip Pinch
Palmar Pinch
Standard Palmar Pinch
- Two point pinch (pincer grasp)
- Three point pinch (three jaw chu
ck․radial distal grasp)
Spherical grasp
Cylindrical grasp
Disc grasp
No Thumb Opposition
Hook
Power grasp
Lateral pinch
Sequential development of grasp
& realse pattern
• Ulnar grasp  palmar grasp  radial grasp
• Palmar contact  finger surface contact 
finger pad contact
• Use of finger flexor  use of intrinsic muscle
with extrinsic muscle
쥐기 발달(grasping)
Milestone of Grasp
-
Primitive Grasp : 0～1개월
Scratching : 3～4개월
Crude Palmar Grasp: 4～5개월
Palmar Grasp : 6개월
Radial Palmar Grasp: 6～7개월
Index Probing : 7～8개월
Instinctive Grasp : 7～8개월
Radial Distal Grasp : 8～9개월
Inferior Pinch : 8～9개월
Superior Pinch : 9～10개월
Three-jaw Chuck : 9～10개월
Fine Pinch Grasp : 11～12개월
- 낙서 : 18개월
- 수직선 : 18～24
개월
- 수평선 : 2.5세
- ○ : 3세
- ＋ : 4세
- □ : 4.5세
- △ : 5세
- ◇ : 6세
Milestone of Release
-
떨어뜨리는 것을 즐김 : 7～8개월
wrist flexion release : 8～9개월
큰 상자에 넣음 : 9～10개월
작은 상자에 넣음 : 11～12개월
적목 2개 쌓기 : 15개월
적목 3～4개 쌓기 : 18개월
적목 6～7개 쌓기 : 24개월
적목 9개 쌓기 : 3세
적목 굴뚝 기차 모방 : 2.5세
다리 : 3세
게이트 : 4～5세
3단 계단 : 5～6세
In-hand manipulation skills
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Finger to palm
Palm to finger
Shift
Simple rotation
Complex rotation
In hand manipulation skills : 8세
정도에 성숙
* 5가지 기본 형태 *
1) finger to palm translation(12～15개월) ; 지갑에
서 동전 꺼내기
2) palm to finger translation(2～2.5세) : 자판기에
돈 넣기
3) shift : 책장 넘기기․구슬 꿰기․글씨 쓰기․가위질
하는 반대 손
4) simple rotation(2～2.5세) : 나사 감고 풀기․퍼즐
조각 돌리기
5) complex rotation(3.5～5.5세) : 연필지우개 사용․
칫솔사용
Development Consideration: in
hand manipulation
• Movement into and stability in various degree of
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supination
Wrist stability
Opposed grasp with thumb opposition and object
contact with the finger surface
Isolated thumb and radial finger movement
Control of the transverse metacarpal arch
Disassociated of the radial and ulnar side of the
hand
Successive increase & decrease in fingertip force
Carrying
• Distal co-contraction
• Shoulder movement
Voluntary release
• 입으로 물건을 고정하고 물건을 transfer 하기
시작: 5-6개월
• Release with stabilizing other hand: 9개월
• Shoulder, elbow의 안정성이 필요
Bilateral hand use: coordination
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Asymmetry-symmetry-differentiated asymmetry
3mo: Asymmetry movement
3-10mo: symmetry patterns predominant
9-10mo: more complex bilateral symmetry skill
8~10mo: differentiated movement 시작
12~18mp: reciprocal & alternating movement
18~24mo: simultaneous manipulation
30 mo: hightly differentiated activity-scissoring
Tool use
• PDMS 에 기초한 발달 소개
2세– 자르기 시작
2.5세– 6인지 종이 자르기
3~ 3.5세– 선자르기
3.5~ 4세- 원자르기
4.5~ 5세- 네모자르기
연필잡기
󰊉 Palmar Supinate Grasp
(1–1.5세)
- 손목 약간 굽혀짐
- 주먹손으로 쥠
- mid-position에서 약간
supination
- arm이 하나의 unit이 됨
󰊉 Digital Pronate Grasp
(2-3세)
- 손가락으로
- 손목 = straight․pronation․
약간 ulnar deviation
- forearm이 하나의 unit이 됨
󰊉 Static Tripod Posture (3.5 - 4세)
- 엄지․검지․중지의 approximation
- 4․5가 약간 구부려져 있음
- 근위부에서 멀리 떨어진 상태에서 잡을
수 있음
- 다른 손으로 재조정함
- 세밀한 움직임이 전혀 나타나지 않음
- hand가 하나의 unit이 됨
󰊉 Dynamic Tripod Posture(4.5- 6세)
- 1․2․3의 정확한 opposition
- 4․5가 안정된 arch를 형성
- wrist가 약간 extention 됨
- 원위부로 잡음
- MCP가 안정된 상태에서 PIP가 움직임
(작은 원 그리기가 가능)
Prerequisites for in-hand manipulation
• Movement into & stability in various degree of
supination
• Wrist stability
• Opposed grasp with thumb opposition &
object contact with the finger surface
• Isolated thumb & radial finger movement
• Control of the transverse metacarpal arch
• Dissociation of the radial & ulnar sides of the
hand
• Successive increases & decreases in fingertip
forces
Relationship of hand skills to
children’s occupations
• Play
• ADL
• School
General motor problems that affect
hand skills
• Inadequate isolation of movement
– Total pattern of flexion or extension
– Unable to combine wrist extension with finger flexion
• Poorly graded movement
– Not effectively graded in range or strength
– Lack the ability to use the middle range of movement
effectively
– Hold one or more joint in a locked position of full extension
or full flexion
– Associated with tactile sensory problem, abnormal tone, &/or
muscle weakness
• Insufficient force
– Interfere with grasp control
– In children with DCD & CP
– Due to poor tactile discrimination, spasticity, &/or muscle
weakness
General motor problems that affect
hand skills
• Poor timing of movement
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Improper timing of muscle contraction
Too fast or too slow for the purpose
Too fast tend to be poorly graded
In children with DCD & CP
Tone problem, muscle weakness, poor coordination of
antagonist & agonist, poor tactile discrimination
• Disorder in bilateral integration of movement
– Affect both the normal symmetric & asymmetric movement
needed to develop & use hand function
– Unable to bring both hands to midline effectively
– Unable to maintain the use of both hands at midline long
enough to accomplish a task
– Difficulty with activity that require reciprocal or simultaneous
bilateral hand use
General motor problems that affect
hand skills
• Limitation in trunk movement & control
– CNS dysfunction or generalized muscle weakness
– Impair development or effective use of equilibrium reaction
– Use one or both arms for support in maintaining sitting or
standing position
– Limit bilateral hand use & development of fine motor skills
– Trunk flexion, functional ROM in the arm is limited
• Compensatory patterns of movement
– Substitute for movement impaired by the primary problem
Other factors
• Somatosensory problems
– Poor tactile discrimination
• Two point discrimination, stereognosis
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Not always associated with the degree of motor impairment
Tactile & proprioceptive information
Tactile defensiveness
Difficulty with feed-forward strategies & with planning for
intentional actions (anticipation of force & timing
• Learned nonuse phenomenon in children with
hemiplegia
• Differences in developmental trends between children
with & without disabilities
– Recognize that normal developmental sequences may not
apply to children with some types of disabilities
Analysis
• Biomechanical frame of reference
– Limitation in ROM, strength, endurance
– Help understand the principles involved in
tenodesis grasping pattern & the relationship of
intrinsic & extrinsic muscle control for grasp & inhand manipulation pattern
– Splinting
• Developmental frame of reference
– Developmental sequence of skills
– Help understand how skills relate to other
developmental skills
Analysis
• Neurodevelopmental frame of reference
– Child’s difficulties with postural tone, postural
control, & stability & mobility
• Sensory integration frame of reference
– Problem with integrating tactile & proprioceptive
information
– Problem with motor planning & sequencing action
despite relatively good motor control
– Difficulty differentiating among the specific sensory
quality of objects
– Somatodyspraxia
Outline assessment tools
• Measurement of AROM, PROM
• Evaluating strength
– Muscle testing
– Grip & pinch strength testing
• Evaluating of tactile & proprioceptive function
– Tactile discrimination, two-point discrimination, finger
identification
• Assessment of postural alignment & stability
– Including stability & mobility of the hand
• Standardized test
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General developmental test Include fine motor section
Developmental motor test
Test of fine motor skills
Visual motor integration test
Prevocational or work task
Guideline for intervention
• Setting goals
– Development skills
– Using adaptive equipment
– Child’s occupational performance problems
– For ADL
Guideline for intervention
• Sequencing of intervention session
– Preparation
• Positioning of the child
• Improvement of postural tone & control
– Development of hand skills
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Promotion of isolated arm & hand movements
Enhancement of reach skills
Enhancement of grasp skills
Enhancement of carrying skills
Enhancement of voluntary release skills
Enhancement of in-hand manipulation skills
Facilitation of bilateral hand use skills
– Generalization of skills
• Integration of hand skills into functional activities
CIMT
Constraint Induced Movement Therapy